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ESSAYS  ON 
GENITOURINARY  SUBJECTS 


ESSAYS 

ON 

GENITOURINARY 
SUBJECTS 


BY 

J.  BAYARD  CLARK,  M.  D. 

ASSISTANT  GENITOURINARY   SURGEON   TO    BELLEVUE   HOSPITAL,  CON- 
SULTING GENITOURINARY   SURGEON  TO  THE   ELIZABETH   GENERAL 
HOSPITAL,    FELLOW   OP    THE    NEW    YORK    ACADEMY    OF  MEDI- 
CINE,    MEMBER     OP    THE     AMERICAN     UROLOGICAL     ASSO- 
CIATION,    MEMBER     OP     THE    AMERICAN     ASSOCIATION 
OF    GENITOURINARY    SURGEONS,    ETC. 


NEW   YORK 

WILLIAM  WOOD  AND  COMPANY 

MDCCCCXII 


/.Lu^i 


v  vi  f-i 


Copyright,  1912 
By  WILLIAM  WOOD  AND  COMPANY 


Printed   by 

The  Maple  Press 

York,  Pa. 


PREFACE 

Through  the  kindly  interest  which  has  been 
shown  in  a  number  of  these  papers  and  the 
many  requests  for  reprints  which  have  ex- 
hausted my  supply,  I  have  been  tempted  to 
bring  these  essays  together  in  the  form  of  a 
small  book. 

An  endeavor  has  been  made  to  bring 
each  topic  up-to-date  by  appending  a  short 
description  of  such  recent  acquirements  as 
have  been  added  to  the  subject  dealt  with. 

In  the  first  chapter  the  description  of 
cryoscopy  has  been  allowed  to  remain 
although  the  method  has  been  practically 
abandoned. 

For  the  right  to  a  new  appearance  of 
Chapters  II,  III,  IV,  V,  and  VI,  I  am  in- 
debted to  the    Medical    Record,   the   New 


PREFACE 

York  Medical  Journal,  the  Medical  News 
and  the  Journal  of  the  American  Medical 
Association. 

In  the  last  three  chapters  which  are 
newly  written  the  writer  has  tried  to  fer- 
tilize the  subjects  considered,  by  a  some- 
what different  angle  of  view  than  is  usually 
given  them. 


CONTENTS 

I    Cystoscopic   Diagnosis    in   Vesical   and 

Renal  Surgery 3 

II    Tuberculous  Kidney 29 

III  Gonococcic  Infections  and  the  Physi- 

cian's Responsibility     49 

IV  Some  Necessary  Principles  in  the  Diag- 

nosis OF  Surgical  Conditions  of  the 

Upper  Urinary  Tract 81 

V    Gonorrheal  Prostatitis loi 

VI    Comparative  Value   of   Some   Urethral 

AND  Other  Germicides 129 

VII    On    What    is    New    in    Genitourinary 

Surgery 141 

VIII    Is  Genitourinary  Surgery  Justified  as  a 

Special  Branch  of  Medicine  ?  .    .    .    .  149 

IX    The  By-ways  of  Prostatectomy     .   .   .   .159 

X    The  Gonococcus 169 


CYSTOSCOPIC  DIAGNOSIS   IN  VESICAL 
AND  RENAL  SURGERY 


CHAPTER  I 

CYSTOSCOPIC  DIAGNOSIS  IN  VESICAL  AND 
RENAL   SURGERY 

The  degree  of  importance  that  the  cystoscope, 
with  its  modern  improvements,  has  attained 
in  the  diagnosis  of  bladder  and  kidney  affec- 
tions, is  not  yet  generally  appreciated. 

A  review  of  some  of  the  more  recent  work 
which  has  been  done  by  the  aid  of  the  cysto- 
scope,  with  a  resum^  of  those  conditions  in 
which  cystoscopy  is  especially  indicated  in  its 
relationship  to  surgery,  will  be  of  interest  to 
those  seeing  this  class  of  cases. 

It  is  not  intended  to  demonstrate  the  virtues 

of  cystoscopy  as  a  method  to  replace  the  longer 

established  means  of  diagnosing  diseases  of 

these  organs,  but  to  show  what  it  has  added 

to  these  means  in  bringing  to  light  those  con- 

[3] 


VESICAL  AND  RENAL  SURGERY 

ditions  of  the  urinary  tract  so  difficult  of 
diagnosis. 

The  Bladder  is  the  seat  of  a  number  of  well- 
known  pathological  conditions  in  the  early 
and  accurate  diagnosis  of  which  the  cystoscope 
plays  the  most  important  r61e. 

Tumors. — Of  all  vesical  conditions  there  are 
none  which  depend  so  absolutely  upon  the 
cystoscope  for  diagnosis  as  neoplasms.  The 
symptoms,  subjective  and  objective,  though 
suggestive,  are  never  sufficient  to  leave  upon 
the  mind  an  image  of  the  real  condition.  It 
is  when  the  new  growth  is  actually  seen,  and 
its  site,  its  size,  its  form,  its  character  in  detail; 
whether  one  or  two  or  more;  if  possible, 
whether  sessile  or  by  a  pedicle  attached,  are 
noted,  that  we  are  in  a  position  to  suggest  a 
diagnosis.  There  are  but  a  few  conditions 
that  stand  in  the  way  of  successful  cystoscopy 
in  these  cases;  i.e.,  where  the  urethra  cannot 
be  made  to  receive  a  cystoscope,  w^here  the 

[4] 


VESICAL  AND  RENAL  SURGERY 

bladder  is  entirely  filled  with  new  growth, 
where  the  transparency  of  the  medium  intro- 
duced cannot  be  kept  momentarily  clear  and 
in  advanced  cases  of  malignant  disease,  which 
cause  unusual  irritability  or  contraction  of 
the  bladder.  When  the  patient  is  seen  early 
enough  most  of  these  difficulties  are  swept 
away. 

Stones. — It  is  said  that  Guyon,  of  Paris,  is 
able  to  determine  the  size,  the  character,  and 
sometimes  the  number  of  calculi  in  the  bladder 
by  means  of  the  metal  searcher.  The  oppor- 
tunities are  certainly  not  given  to  surgeons  of 
this  part  of  the  country  to  attain  such  skill, 
nor  is  it  necessary,  for  the  cystoscope  can  be 
used  with  as  little  risk  and  as  little  discomfort 
to  the  patient  as  the  stone  searcher,  and  with 
an  infinitely  more  satisfactory  result.  The 
exact  position  of  the  stone  is  learned,  and 
whether  it  be  encysted  or  free ;  the  number  of 
stones,  if  not  too  many,  is  ascertained;  and 

[5] 


VESICAL  AND  RENAL  SURGERY 

what  is  more,  the  state  of  the  bladder  wall  and 
existing  complications  are  noted.  After  lith- 
olapaxy  it  is  especially  important  to  see  whether 
all  the  particles  of  stone  have  been  gotten  rid 
of,  for  if  a  small  fragment  remains  it  will  serve 
as  a  nucleus  for  new  calculus  formation. 

Prostatic  Hypertrophy. — There  are  a  certain 
number  of  cases  where  the  urethral  distance  or 
tortuosity,  where  the  cystitis  or  the  easily 
excited  hemorrhage  puts  cystoscopy  out  of 
the  question.  In  these  cases  a  correct  esti- 
mation of  the  extent  and  character  of  intra- 
vesical enlargement  or  vesical  complications, 
as  tumor,  stone,  etc.,  cannot  be  made,  and, 
therefore,  we  cannot  expect  to  institute  such 
effective  treatment  nor  give  by  surgical  inter- 
vention such  uniform  results  as  in  the  other 
and  fortunately  larger  class,  where  by  the 
cystoscope  we  learn  the  vesical  aspect  of  the 
prostate,  the  internal  orifite,  the  has  fondy 
and  the  condition  of  the  bladder,  its  mucous 

[6] 


VESICAL  AND  RENAL  SURGERY 

membrane,  its  musculature,  its  ureters  and 
their  doings ;  and  with  this  knowledge  proceed 
to  treatment. 

Foreign  Bodies  such  as  pins,  pieces  of 
catheter,  silk  sutures,  etc.,  are  met  with  at 
rare  intervals  in'the  bladder,  and  are  generally 
very  easily  identified. 

Other  vesical  conditions  which  are  studied 
by  the  cystoscope,  such  as  cystitis,  vesical 
tuberculosis,  ulcers,  varicosities,  diverticula, 
vesicles  and  bulbous  edema,  will  not  be  con- 
sidered in  this  paper,  as  they  do  not  come 
under  the  head  of  those  affections  ordinarily 
requiring  surgical  intervention. 

The  Kidneys. — Through  the  agency  of  the 
cystoscope  and  ureteral  catheterization  it  has 
become  possible  to  make  the  diagnosis  in 
cases  where  the  most  careful  observation  of 
all  clinical  signs  leaves  the  real  condition  un- 
determined. But  besides  diagnosis,  perhaps 
the  most  important  realm  of  usefulness  lies 

l7] 


VESICAL  AND  RENAL  SURGERY 

in  the  field  upon  which  we  are  just  entering, 
where  a  true  estimate  of  the  functional  activity 
and  ability  of  the  separate  kidneys  is  sought. 
And  here  is  added  a  new  responsibility  for 
all  those  doing  kidney  work,  and  an  obligation 
to  every  patient  of  this  class ;  for  to  remove  the 
kidney  on  one  side  without  having  previously 
attempted  to  determine  the  functionating 
power  of  the  other  gland,  which  is  destined  to 
perform  the  entire  work  of  renal  elimination 
for  the  body,  is  surgery  which  should  be  no 
more. 

As  to  Diagnosis. — Before  the  day  of  the 
cystoscope  the  observation  of  the  clinical 
picture,  with  its  characteristic  subjective 
symptoms,  and  the  exact  examination  of  the 
urine,  with  the  objective  knowledge  gained 
through  palpation  and  percussion,  were  the 
means  we  had  at  hand  to  solve  the  difficult 
diagnostic  problems  of  the  urinary  system. 
The  value  of  these  means  is  not  contended, 

[8] 


VESICAL  AND  RENAL  SURGERY 

but  in  many  cases  they  are  insufficient.  To 
show  how  misleading  are  subjective  symp- 
toms :  There  may  be  pain  in  the  left  kidney 
when  the  right  is  the  seat  of  disease.  That 
pain  which  is  characteristic  of  the  pres- 
ence of  bladder  or  kidney  stone  may  be  en- 
tirely absent.  Great  urgency  of  micturition 
is  most  often  due  to  trouble  about  the  vesical 
sphincter  or  prostatic  urethra,  yet  pyelitis  and 
renal  calculus  may  cause  this  same  frequency. 
With  pain  in  the  glans  penis  the  trouble  may 
be  either  in  the  bladder  or  the  kidney.  Pain 
may  come  in  attacks,  as  is  ordinary  with 
kidney  stone;  yet  pyelitis  or  temporary 
blocking  of  the  ureter  may  give  the  same  kind 
of  attacks. 

For  objective  symptoms  we  have  the  urine 
alone  to  reply  upon,  in  very  many  instances, 
but  its  change  from  normal,  its  admixture  with 
blood  or  pus  or  bacteria  or  whatever  it  may 
be,  tell  us  but  part  of  the  story.    It  does  not 

[9] 


VESICAL  AND  RENAL  SURGERY 

tell  us  from  which  kidney  or  ureter,  or  whether 
from  the  bladder  or  urethra,  the  abnormal 
elements  arise.  Here,  then,  is  indication  for 
the  cystoscope  and  urethral  catheter,  with 
which  positive  information  is  gained  in  the 
following  manner: 

It  is  a  good  rule  first  to  employ  the  simple 
cystoscope,  which  is  smaller  of  caliber  and 
gives  a  broader  field  of  observation.  A 
general  survey  of  the  bladder  is  made  and 
vesical  complications,  if  present,  are  noted. 
The  attention  is  then  centered  about  the 
ureters,  and  indications  of  disease  higher  up 
are  here  carefully  looked  for.  The  mucous 
membrane  around  one  or  the  other  ureter  may, 
for  example,  show  ulceration  or  small  tuber- 
cles, suggestive  of  descending  tubercular 
infection  of  the  kidney  and  ureter  of  that 
side.  The  ureteral  lips  may  be  thickened, 
and  the  orifice  patent  and  devoid  of  its 
normal  function  of  opening  and  closing  as 

[lo] 


VESICAL  AND  RENAL  SURGERY 

the  little  jet  of  urine  is  emitted,  which  gives 
evidence  of  some  hindrance  to  the  passage  of 
urine  below  this  point,  and  the  possibility  of 
consequent  upward  infection.  The  lips  of 
the  ureter  may  be  pouting  or  its  mucous 
membrane  more  or  less  prolapsed,  which 
condition  occurs  with  blocking  of  the  ureter, 
usually  by  calculus  not  far  above  its  orifice. 
Finally,  we  note  with  especial  care  the  tiny 
stream  of  urine  itself,  the  action  of  the 
ureter-mouth,  the  amount  of  urine,  the 
intervals  between  the  issued  jets  or  drops, 
and  the  character  of  the  secretion  as  it 
appears,  whether  bloody  or  mixed  with  pus, 
or  thickened  as  by  mucus.  The  difference 
between  the  two  sides  is  then  observed. 
If  one  or  both  sides  fail  to  functionate  such 
fact  is  noted. 

In  this  way,  before  attempting  to  collect  by 
ureteral  catheterization  the  separate  urines, 
we    have    come    into    possession    of    much 

[II] 


VESICAL  AND  RENAL  SURGERY 

valuable  information,  for  we  have  ascertained 
that  the  trouble  comes  not  from  urethra  or 
bladder,  but  from  above  these  points.  We 
have  also  gained  evidence  as  to  the  side  of 
the  lesion  and  suggestions  as  to  its  nature. 
The  ureteral  catheter  now  gives  us  the 
means  to  determine  more  exactly  the  site  of 
the  lesion,  and  by  analysis  of  the  urine  thus 
obtained,  its  nature.  Without  question  the 
only  accurate  method  of  obtaining  the  sepa- 
rate urines  without  fear  of  admixture  or 
contamination  with  the  urine  from  the 
opposite  side  or  from  the  bladder  is  by  ureteral 
catheterization.  This  procedure  is  applicable 
and  possible  in  the  majority  of  cases.  That  it 
is  accomplished  with  but  little  discomfort  to 
the  patient  and  little  danger  of  infection 
stands  to-day  proved  by  ample  experience. 

Among  those  conditions  of  the  kidneys 
brought  within  the  scope  of  this  means  of 
diagnosis  are:  Renal  tuberculosis,  unilateral 

[12] 


VESICAL  AND  RENAL  SURGERY 

nephritis,  pyelitis,  pyonephrosis,  pyeloneph- 
ritis, hydronephrosis,  atrophic  kidney,  single 
kidney,  and  at  times  new  growths.  In 
addition  must  be  mentioned  those  instances 
where  the  ureteral  catheter  is  used  as  a  sound 
to  detect  abnormal  constrictions  and  blocldng 
of  the  ureter  by  stricture,  stones,  new  growths, 
etc.  Kelly,  of  Baltimore,  says  that  he  has 
demonstrated  the  presence  of  stone  by  bring- 
ing a  ureteral  catheter  tipped  with  impres- 
sionable wax  in  contact  with  it.  Tilden 
Brown  and  others  have  introduced  the 
catheter  incasing  a  fine  metal  stylet  as  far  as 
the  kidney  pelvis,  and  then  by  a  radiograph 
have  demonstrated  a  dislocation  of  the 
kidney  or  cleared  up  the  differential  diagnosis 
between  abdominal  tumor  and  kidney. 

Before  speaking  of  the  determination  of 
renal  sufficiency  the  names  of  v.  Koranyi,  of 
Budapest;  Casper  and  Richter,  of  Berlin; 
Kummell,   of  Hamburg,   and  Albarron,   of 

[13] 


VESICAL  AND  RENAL  SURGERY 

Paris,  should  be  mentioned  as  those  men  who 
by  patient  work  and  painstaking  experiments 
have  done  the  most  in  perfecting  those  means 
we  now  have  at  hand  to  estimate  the  functional 
ability  of  the  respective  kidneys.  No  more 
than  a  brief  sketch  of  this  subject  will  be 
attempted,  as  the  writer's  object  is  simply  to 
bring  the  main  points  to  the  attention  of 
those  whose  interest  will  lead  them  further  in 
this  line  of  thought  and  work. 

We  have  seen  how  by  ureteral  catheterization 
we  can  make  anatomical  diagnoses  of  kidney 
affections;  so  is  it  possible  to  turn  this  same 
means  to  account  in  making  functional  diag- 
noses of  the  kidneys,  which,  in  other  words, 
means  a  measure  of  the  amount  of  work  of 
these  organs — not  of  their  united  power  how- 
ever, but  the  estimate  of  what  each  indi- 
vidual kidney  can  do.  This  is  the  important 
thing  from  a  surgical  standpoint. 

We  are  confronted  in  every  case  of  surgical 

[14] 


VESICAL  AND  RENAL  SURGERY 

kidney  disease  by  these  questions :  How  much 
kidney  parenchyma  capable  of  work  still 
exists  ?  Is  it  sufficient  to  perform  its  function 
of  ridding  the  body  of  the  waste  products  of 
metabolism?  How  is  this  work  divided  and 
to  what  extent  does  each  kidney  participate  ? 
The  importance  of  gaining  this  knowledge  in 
every  case  of  suspected  kidney  disorder  of  a 
surgical  nature  is  emphasized  when  one  sees 
in  the  literature  what  a  number  of  cases  have 
been  reported,  where  only  a  single  kidney  is 
found,  where  the  kidney  of  one  side  has  in 
part  or  entirely  degenerated,  or  where  al- 
though the  second  kidney  was  present,  it 
was  so  far  diseased  that  on  removal  of  the 
opposite  organ  it  was  incapable  of  performing 
sufficient  work  to  maintain  life.  When  to  the 
cases  which  have  been  observed  and  reported 
are  added  those  which  have  not  come  to 
autopsy,  and  therefore  could  not  be  reported, 
although  they  undoubtedly  occurred,  we  see 

[15] 


VESICAL  AND  RENAL  SURGERY 

that  it  is  possible  very  considerably  to  lessen 
the  mortality  in  surgical  kidney  disease,  if 
we  are  able  to  determine  this  question  of 
sufficient  or  insufficient  renal  function. 

The  methods  to  this  end  which  have  been 
used  and  proved  of  practical  value  will  be 
mentioned,  and  those  means  which  are  not 
to-day  found  useful,  though  worthy  of  our 
respect  for  having  paved  the  way  for  better 
things,  will  be  omitted. 

The  Determination  0}  the  Freezing  Point 
0}  the  Blood  and  Urine  (Cryoscopy.) — This 
method  depends  upon  that  physiological 
power  possessed  by  the  kidneys,  which  so 
regulates  the  osmotic  pressure  that  it  main- 
tains in  those  fluids  with  which  it  has  to  do, 
namely  the  blood  and  urine,  a  constant 
measurable  degree  of  molecular  concentration 
which  is  determined  by  their  freezing  points. 
As  the  concentration  of  the  fluid  is  increased, 

so  is  its  freezing  point  lowered  below  that  of 

[16] 


VESICAL  AND  RENAL  SURGERY 

distilled  water.  It  is  to  be  understood  when 
molecular  concentration  is  mentioned  that  the 
concentration  in  an  osmotic  sense  is  meant, 
for  a  purely  physical  molecular  concentration 
can  exist  without  influence  upon  the  point  at 
which  the  fluid  freezes,  for  example,  the 
amount  of  albumin  in  the  urine  of  kidney 
patients  influences  the  specific  gravity  while 
it  has  no  bearing  on  the  lowering  of  the  freez- 
ing point.  A.  V.  Koranyi  and  others  have 
shown  that  the  blood  of  individuals  with 
normal  or  sufficient  kidney  function  freezes  at 
— 0.56  degrees  C,  that  the  urine  in  these 
cases  freezes  at  from — i.o  degrees  to — 2.0 
degrees  C.  Where  the  kidney  function  is  in- 
sufficient, the  molecular  concentration  of  the 
blood  is  increased  and  the  freezing  point  is 
lowered,  and  with  this  goes  a  higher  freezing 
point  for  the  urine. 

When  the  normal  freezing  point  of  the  blood 

tells  us  that  there  is  enough  healthy  kidney 

2  [17] 


VESICAL  AND  RENAL  SURGERY 

parenchyma  to  free  the  body  of  its  waste  prod- 
ucts, it  does  not  show  which  kidney,  or 
whether  each  kidney  in  part,  is  carrying  on 
the  work.  For  this  information  we  rely  on 
the  freezing  of  the  separate  urines,  along  with 
the  chemical  and  microscopical  examination, 
the  phloridzin  test,  etc. 

Backmann's  cryoscopic  apparatus  is  the  one 
ordinarily  used.  It  consists  of  a  cylindrical 
jar  about  6  inches  high  by  4  inches  or  5  inches 
in  diameter.  This  is  filled  with  a  freezing 
mixture  of  ice  and  salt,  in  the  center  of  which 
is  placed  a  tube  about  1 1/2  inches  in  diameter. 
In  this  latter  is  placed  a  somewhat  smaller 
tube  so  that  an  air  space  between  the  two 
exists,  insuring  an  even  conduction  of  cold 
to  the  inner  tube  which  contains  the  blood  or 
urine  to  be  tested.  Fifteen  to  twenty  cubic 
centimeters  is  the  amount  found  most  con- 
venient, and  in  this  is  placed  the  thermom- 
eter with    scale  divided  into  hundredths  of 

[18] 


VESICAL  AND  RENAL  SURGERY 

degrees;  alongside  of  the  thermometer  is  a 

mixer  made  of  platinum  wire  and  bent  at  its 

lower  extremity  so  as  to  encircle  the  lower 

end  of  the  thermometer;   a  cork  perforated 

for  the  thermometer  and  mixer  closes  the 

tube. 
The  freezing  point  of  distilled  water  is  first 

determined  and  afterward  that  of  the  urine; 
the  difference  between  the  two  is  the  freezing 
point  sought.  This  for  the  urine  is  desig- 
nated after  the  plan  of  Koranyi  by  A  and 
for  the  blood  by  8.  While  freezing,  the  speci- 
men is  constantly  stirred  by  the  mixer  and 
the  column  of  mercury  is  closely  watched. 
It  moves  first  rather  slowly,  but  with  increasing 
velocity  it  sinks  until  it  has  reached  a  point 
some  distance  below  the  freezing  point, 
when  in  consequence  of  the  warmth  set  free 
by  freezing  it  rises  to  the  point  at  which  it 
freezes  and  there  remains  for  a  short  time, 
during  which  the  reading  is  made. 

[19] 


VESICAL  AND  RENAL  SURGERY 

The  usefulness  of  this  method,  as  pointed 
out  by  Casper  and  Richter,  is  that  it  is  a  test 
of  the  renal  activity  as  a  whole,  whereas  the 
methylene  blue  or  other  similar  tests  show 
only  the  power  of  the  kidney  in  one  phase, 
and  therefore  give  no  idea  of  its  natural 
functionating  ability  in  eliminating  the  total 
of  the  solid  molecules. 

As  mentioned  before,  it  is  the  combination 
of  ureteral  catheterization  and  the  freezing 
point  determination  of  the  separate  urines 
which  is  of  especial  value  in  forming  judg- 
ment as  to  the  power  of  each  organ;  for  it 
is  the  comparative  values  which  we  wish  to 
obtain.  The  phloridzin  test  is  an  added 
proof  of  what  each  kidney  is  capable  of, 
when  used  in  conjunction  with  the  freezing 
point  determination.  The  action  of  this  drug 
is  chiefly  on  the  kidneys  and  its  result  a  so- 
.called  phloridzin-glycosuria.     Small  amounts 

(.005   grams),   injected  subcutaneously,   are 

[20] 


VESICAL  AND  RENAL  SURGERY 

best  suited  for  the  results  and  are  in  no  way 
harmful.  The  effect  lasts  but  about  three 
hours,  beginning  fifteen  to  thirty  minutes 
after  injection.  The  test  is  based  on  the 
amount  of  sugar  excreted,  but  a  delay  in  the 
sugar  elimination  is  also  a  factor.  The 
phloridzin  method  is  useful  because  expressi- 
ble in  figures  and  comparative  results  of  the 
two  sides  indicate  the  amount  of  functionating 
parenchyma  present. 

The  elimination  of  nitrogen  or  its  chief 
representative  urea,  when  taken  as  a  measure 
of  the  work  of  both  kidneys,  is  of  unstable 
value,  for  patients  with  kidney  disease  have 
periods  of  good  and  bad  N-elimination. 
Even  healthy  individuals  may  have  periods 
of  retained  nitrogen.  On  the  other  hand, 
an  estimation  of  the  amount  of  nitrogen  from 
each  kidney  gives,  in  a  differential  way,  a 
valuable  index  of  the  renal  ability,  and 
considered  with  those  methods  already  men- 

[21] 


VESICAL  AND  RENAL  SURGERY 

tioned,  forms  an  important  link  in  that  chain 
of  evidence  we  seek. 


Since  the  appearance  of  this  paper  a  new 
phase  has  been  added  to  our  idea  of  measur- 
ing kidney  abihty.  The  brilhant  work  of 
Geraghty  and  Rowntree  with  phenolsul- 
phonephthalein  holds  the  promise  of  a  simple 
and  more  accurate  means,  and  a  test  of 
far  broader  application  than  those  that 
have  gone  before;  such  as  cryoscopy,  elec- 
trical conductivity  of  the  urine,  the  color  and 
phloridzin  tests. 

For  a  working  knowledge  of  the  phenol- 
sulphonephthalein  test  for  estimating  renal 
function  the  reader  is  referred  to  the  authors 
of  this  work.  I  will  give  here  only  an  outline 
of  this  test  in  its  technical  application. 

One  cubic  centimeter  of  the  solution  of  the 
drug  containing  6  mgm.  is  injected  subcu- 
taneously  and  the  time  is  noted.     The  patient 

[22] 


VESICAL  AND  RENAL  SURGERY 

empties  his  bladder  and  a  catheter  is  aseptic- 
ally  introduced.  The  urine  is  allowed  to 
drain  into  a  test  tube  containing  a  drop  of  25 
per  cent,  sodium  hydrate.  On  the  appear- 
ance of  the  drug  there  is  a  marked  pink  color 
and  the  time  is  again  noted.  The  catheter 
can  then  be  withdrawn,  or  clamped  if  the 
case  is  one  of  urinary  obstruction.  At  the 
end  of  one  hour  the  urine  is  collected  and 
again  at  the  end  of  the  second  hour  in  a 
second  receptacle.  The  specimens  are  made 
strongly  alkaline  with  the  25  per  cent,  sodium 
hydrate  solution  which  brings  out  the  purple 
red  color.  They  are  then  diluted  to  exactly 
one  liter  with  distilled  water.  They  are  then 
compared  with  a  standard  solution  containing 
a  known  amount  of  the  drug  to  the  liter.  A 
Dubosc  colorimeter  is  used  for  the  color  com- 
parison or  a  set  of  test  tubes  filled  with  solu- 
tions of  known  strength  is  employed,  and 
the  reading  made. 

[23] 


VESICAL  AND  RENAL  SURGERY 

In  a  series  of  several  hundred  normal  cases 
the  originators  of  this  method  found  that  the 
drug  appeared  in  the  urine  in  from  five  to 
eleven  minutes,  38  to  60  per  cent,  (average 
50  per  cent.)  being  excreted  in  the  first  hour 
after  its  appearance  in  the  urine,  and  60  to 
85  per  cent,  for  two  hours.  The  elimination 
being  practically  completed  in  the  two  hours. 
In  a  second  series  of  cases  intra-muscular  and 
intra- venous  injections  were  used.  With  the 
intra-muscular  injections  the  time  of  appear- 
ance is  about  the  same  but  the  output  averages 
5  to  10  per  cent,  more  for  the  first  hour. 
Following  intra- venous  injections  the  drug 
appeared  in  from  three  to  five  minutes  and 
from  35  to  45  per  cent,  of  the  drug  was  elimin- 
ated in  the  first  fifteen  minutes,  50  to  65  per 
cent,  in  the  first  half  hour  and  6^  to  80  per 
cent,  during  the  first  hour.  The  intra- 
muscular method  for  general  use  is  recom- 
mended.   With  the  normal  cases  as  a  stan- 

[24] 


VESICAL  AND  RENAL  SURGERY 

dard  patients  with  nephritis,  uremia,  cardiac 
and  cardio-renal  lesions,  patients  with  urinary 
obstruction  of  the  lower  urinary  tract,  and 
unilateral  and  bi-lateral  surgical  diseases  of 
the  kidneys  were  studied.  Delay  in  elimin- 
ation of  the  drug  and  decreased  percentages 
of  elimination  during  the  standard  periods  of 
collection,  constituted  the  degree  of  failure 
of  the  kidneys  studied  in  carrying  out  their 
normal  function. 


[25] 


II 

TUBERCULOUS   KIDNEY 


CHAPTER  II 

TUBERCULOUS   KIDNEY 

The  following  case  is  reported  because  the 
steps  toward  diagnosis  were  interesting,  as 
illustrating  the  usefulness  of  the  cystoscope, 
the  cryoscopic  examination  of  the  blood,  and 
in  this  instance  the  radiograph. 

Case. — B.  McM.,  a  young  Irish  woman, 
single,  twenty-eight  years  old  and  employed 
as  a  domestic,  was  very  kindly  sent  to  me  for 
diagnosis  and  treatment  by  Dr.  F.  Tilden 
Brown.  She  was  admitted  to  Trinity  Hospi- 
tal November  27,  1904. 

Her  father  died  of  pleurisy  at  the  age  of 
forty-one,  otherwise  her  family  history  was 
unimportant.  She  came  to  this  country  six 
years  ago.     She  had  always  been  perfectly 

[29] 


TUBERCULOUS  KIDNEY 

healthy  and  able  to  work.  Three  years  ago 
she  commenced  to  suffer  occasionally  with  a 
rather  sharp  pain  in  the  lumbar  region,  which 
would  last  an  hour  or  two,  and  which  she 
thought  was  more  on  the  right  side  than  on  the 
left.  This  continued  for  a  little  over  a  year, 
when  she  first  noticed  that  she  had  to  pass 
her  urine  more  frequently  than  usual  and  that 
it  was  attended  with  some  discomfort.  The 
pains  in  the  back  at  this  time  seemed  to  dis- 
appear and  the  frequency  of  micturition  in- 
creased rapidly,  until  at  the  end  of  a  month 
she  was  compelled  to  urinate  every  fifteen  or 
twenty  minutes  during  the  day,  and  five  or 
six  times  at  night.  The  discomfort  which  had 
attended  urination  developed  into  a  burning 
pain,  most  intense  as  the  last  few  drops  of 
urine  were  being  voided. 

She  then  consulted  a  physician,  who  ex- 
amined her  urine  and  told  her  she  was  suffer- 
ing from  catarrh  of  the  bladder.    Internal 
.    [30] 


TUBERCULOUS  KIDNEY 

remedies  were  prescribed,  but  the  condition 
was  not  relieved.  Five  months  dragged  along 
in  this  way  and  she  then  entered  a  hospital, 
where  she  remained  for  six  weeks,  during  that 
time  she  received  as  treatment  irrigations  of 
the  bladder.  When  she  left  the  hospital  her 
urination  was  somewhat  less  frequent  but 
more  painful.  She  returned  to  work,  and  for 
a  little  over  a  year  she  attended  to  her  duties, 
in  the  meantime  receiving  by  way  of  treat- 
ment more  bladder  irrigations.  At  this  time 
she  noticed  that  she  occasionally  passed  a 
little  blood  at  the  end  of  urination.  She  lost 
thirty  pounds  in  weight,  from  156  to  126 
pounds,  and  had  become  too  weak  to  attend 
to  her  work  any  longer. 
Physical  Examination. — The  loss  of  weight 

was  evident,  but  she  was  not  emaciated. 
Somewhat  anemic,  cheeks  flushed;  heart  and 
lungs  were  normal;  abdomen,  except  for  the 
following,  was  normal :  the  lower  pale  of  right 

[31] 


TUBERCULOUS  KIDNEY 

kidney  could  be  felt,  but  no  more  than  in 
many  healthy  females ;  it  did  not  appear  to  be 
enlarged;  there  was  no  tenderness.  The  only 
point  of  tenderness  on  pressure  was  over  the 
urinary  bladder.  The  external  genitals  were 
normal ;  bimanual  examination  revealed  noth- 
ing abnormal  further  than  tenderness  of  the 
bladder.  The  patient  was  put  to  bed  on  a 
light,  nourishing  diet,  the  only  medication 
being  five  grains  of  salol  three  times  a  day,  by 
way  of  preparation  for  a  cystoscopic  ex- 
amination a  few  days  later. 

November  28. — ^First  day  after  admission  to 
hospital,  the  urine  analysis  of  a  catheterized 
specimen  showed  a  cloudy  pale  amber  urine, 
specific  gravity  1.012,  amphoteric  reaction,  a 
trace  of  albumin,  no  sugar,  no  bile,  small 
amount  of  indican,  urea  .81  per  cent,  and 
chlorides  1.14  per  cent.  The  microscope 
showed  a  small  amount  of  mucus,  a  moderate 
amount  of  pus,  no  blood  or  casts,  a  few 

[32] 


TUBERCULOUS  KIDNEY 

bladder  epithelia.  No  tubercle  bacilli  were 
found. 

At  the  end  of  a  week  the  following  observa- 
tions were  made:  An  afternoon  rise  of  tem- 
perature of  6/10  to  8/10  of  a  degree  F.,  a  pulse 
between  70  and  80,  average  amount  of  urine 
for  twenty-four  hours,  47  ounces,  average 
number  of  times  urine  was  passed  in  twenty- 
four  hours,  ten;  average  amount  each  time, 
between  four  and  five  ounces;  urination  a 
little  less  frequent  during  the  night;  patient 
sleeping  well  during  intervals,  and  preserving 
a  fair  appetite. 

Up  to  this  time  there  was  nothing  upon 
which  to  build  a  diagnosis.  The  history  was 
merely  suggestive.  The  physical  examina- 
tion and  the  urinary  analysis  simply  bore  out 
the  previous  supposition  of  a  bladder  affection. 

December  7. — Under  cocaine  anesthesia  a 
thorough  cystoscopic  examination  was  made. 
The  base  of  the  bladder  on  the  right  side  was 
3  [33] 


TUBERCULOUS  KIDNEY 

slightly  hyperemic,  especially  the  trigone. 
The  right  ureteric  orifice  was  about  three  times 
larger  than  its  fellow,  elliptical  in  form,  margin 
thickened  and  rigid,  all  muscular  action  had 
gone;  it  remained  open  and  its  cavity  was 
highly  inflamed,  small  jets  of  cloudy  urine 
issued  infrequently.  Backward  and  to  the 
right  of  this  ureter-mouth  for  about  2  cm.,  a 
cord-like  elevation  of  the  mucous  membrane 
could  be  seen ;  this  I  took  to  be  the  thickened 
intra-mural  portion  of  the  ureter.  At  about 
the  upper  extremity  of  this  was  an  irregularly 
ulcerated  area  about  one  centimeter  in  diam- 
eter; leading  from  this  upward  to  the  fundus 
of  the  bladder  was  a  narrow  ulcerated  path 
which  terminated  in  another  irregular  ulcera- 
tion, which  was  twice  the  size  of  the  first ;  this 
was  flecked  with  small  grayish-white  patches, 
and  was  surrounded  with  ablush  of  hyperemia. 
Except  for  a  low  grade  of  inflammation  which 
gave  the  mucous  membrane  a  slightly  softer 

[34] 


TUBERCULOUS  KIDNEY 

appearance,  the  rest  of  the  viscus  was  negative, 
including  the  left  ureter  mouth,  which  gave 
forth  at  frequent  intervals,  jets  of  clear  urine. 

This  examination  made,  to  my  mind, 
tuberculosis  of  the  right  kidney  extremely 
probable.  Frequent  examinations  of  the  urine 
for  tubercle  bacilli  were  then  instituted,  and 
continued  for  about  three  weeks  without 
avail.  Guinea-pigs  were  then  inoculated  but 
died  of  sepsis  within  a  week  or  ten  days. 
Tubercle  bacilli  were  found,  however,  on  two 
occasions  within  this  time  in  the  urine.  They 
were  in  very  small  numbers  but  character- 
istically grouped. 

The  next  step  in  the  process  of  diagnosis 
was  to  obtain  the  separate  urines,  with  a 
view  not  only  of  learning  more  accurately  the 
condition  of  the  diseased  organ,  but  of 
getting  an  estimate  of  the  functionating 
capacity  of  its  fellow. 

On  January  3,  a  catheterizing  cystoscope 

[35] 


TUBERCULOUS  KIDNEY 

was  introduced.  It  was  found  impossible  to 
advance  a  catheter  beyond  the  mouth  of  the 
right  ureter,  on  account  of  obstruction  un- 
doubtedly due  to  its  diseased  condition  at 
that  point.  The  left  ureter  was  easily  cath- 
eterized  and  i6  c.c.  of  clear,  light-colored 
urine  obtained.  This,  on  examination,  was 
of  neutral  reaction,  no  sugar  or  albumin  pre- 
sent, urea  1.5  per  cent.  The  microscope 
showed  a  few  red  blood  cells  and  epithelia, 
which  commonly  occur  with  the  use  of  the 
ureteral  catheter.  No  tubercle  bacilli  were 
found. 

It  will  be  seen  that  this  urine  was  that  of  a 
healthy  kidney  and  that  the  abnormal  ele- 
ments previously  obtained  came  from  the 
right  kidney  and  ureter,  with  the  bladder 
participating. 

To  make  more  sure  of  sufficient  renal 
function,  Dr.  Alfred  T.  Osgood  was  good 
enough  to  determine  the  freezing  point  of  the 

[36] 


TUBERCULOUS  KIDNEY 

blood,  which  was   —0.55  degrees  C,  thus 
showing  no  undue  molecular  concentration. 

I  then  took  the  patient  to  Dr.  L.  G.  Cole, 
who  took  an  excellent  radiograph.  The 
picture  added  much  weight  to  the  evidence 
already  collected,  for  it  showed  a  shadow  of 
considerable  density,  the  outline  of  which 
softened  out  almost  too  gradually  to  be  mis- 
taken for  a  stone.  A  growth  of  firm  con- 
nective tissue  replacing  parenchyma  seemed 
the  most  likely  interpretation,  and  the  correct 
one,  as  the  specimen  later  showed. 

The  diagnosis  was  then  as  follows :  Primary 
tuberculosis  of  the  right  kidney  with  extensive 
destruction  of  the  organ  and  extension  of  the 
process  to  the  bladder.  The  left  kidney  func- 
tionally capable  of  carrying  on  the  work  of 
elimination  for  the  body. 

On  January  18, 1  removed  the  right  kidney 
by  the  extraperitoneal  route. 

Pathological    Examination    of    Kidney. — 

[37] 


TUBERCULOUS  KIDNEY 

Weight,  144  grams;  length,  10.5  cm.;  width, 
4.5  cm.;  thickness,  4.5  cm.  Gross  appear- 
ance: The  surface  retains  the  type  of  fetal 
lobulation.  Through  the  capsule  are  seen 
many  small  foci  about  pinhead  size,  which 
resemble  miliary  tubercles.  These  are  most 
numerous  about  the  central  zone  of  the 
organ.  There  is  a  marked  engorgement  of 
the  vessels  beneath  the  capsule  and  an  exten- 
sive subcapsular  hemorrhagic  exudate,  giving 
a  dark  red  color  to  almost  the  entire  extent  of 
the  sufrace.  Section  through  the  convexity 
of  the  organ  in  its  longitudinal  axis  shows  the 
following:  Average  length  of  pyramids,  2.8 
cm.;  average  thickness  of  cortex,  0.6  cm. 
A  thin  hemorrhagic  zone  beneath  the  capsule. 
Cortex  very  light-gray  color,  markings  oblit- 
erated, line  of  junction  with  medulla  indistinct, 
in  places  indistinguishable.  Occasional  small 
gray  bodies,  pinhead  in  size,  which  resemble 
tubercles. 

[38] 


TUBERCULOUS  KIDNEY 

The  medulla  has  almost  lost  its  identity  by 
being  converted  into  a  grayish  fibrous  tissue, 
in  which  there  are  abscess  cavities,  the  largest 
measuring  2  cm.  in  diameter.  The  two 
largest  of  these  cavities  encroach  on  the  cortex, 
and  are  lined  by  cheesy-looking  material,  and 
about  one  is  a  considerable  hemorrhagic 
exudate. 

The  pelvic  wall  is  thickened  and  contracted. 
Its  mucosa  has  a  rough,  cheesy-looking 
appearance.  At  one  point  in  the  fibrous 
portion  of  the  wall,  is  a  hemorrhagic  exudate 
1.5  cm.  in  diameter. 

The  blood-vessels  show  some  thickening. 

Microscopic  Examination. — Connective  tis- 
sue system.  The  capsule  is  represented  by  a 
thin,  ragged  layer  of  fibrous  tissue  which  is 
permeated  by  inflammatory  exudate.  Be- 
neath the  capsule  there  is  a  layer  of  vascular 
fibrous  tissue  of  considerable  thickness.  The 
fibrous   tissue   passes   into   the   medulla   in 

[39] 


TUBERCULOUS  KIDNEY 

places  as  broad  bands  of  connective  tissue. 
The  fibrous  tissue  is  quite  cellular  and  there 
are  many  areas  of  small,  round-cell  infiltra- 
tions. There  are  many  miliary  tubercles 
scattered  through  the  newly  formed  tissue. 
They  are  mainly  fibrous  in  the  cortex,  but  in 
the  medulla  they  are  represented  by  large 
areas  of  coagulated  necrosis  surrounded  by 
fibrous  tissue.  Many  giant  cells  are  asso- 
ciated with  these  tubercles.  The  newly 
formed  tissue  beneath  the  capsule  is  infil- 
trated by  hemorrhagic  exudate.  The  capsule 
of  Bowman  in  many  places  is  much  thickened. 
The  intertubular  tissue  is  increased  in  strands 
and  islands.  A  few  places  present  the  normal 
amount  of  stroma. 

Parenchymatous  System. — In  the  fibrous 
tissue  zone  beneath  the  capsule,  the  tubules 
have  almost  entirely  disappeared.  An  occa- 
sional tubule  can  be  seen  much  diminished  in 
size   with   the   epithelium   desquamated   or 

[40] 


TUBERCULOUS  KIDNEYS 

flattened.  Some  contain  hyaline  casts,  others 
hemorrhagic  exudate.  There  is  extensive 
parenchymatous  degeneration  and  disinte- 
gration of  the  renal  epithelium  generally. 
Some  of  the  tubules  are  dilated,  and  their  epi- 
thelium flattened,  others  have  their  lumen 
completely  filled  by  their  swollen  epithelium. 
In  some  instances,  the  epithelium  is  entirely 
desquamated  and  the  tubule  empty.  Some 
contain  hemorrhagic  exudate,  others  casts. 

Vascular  System. — The  walls  of  the  large 
vessels  are  slightly  thickened,  in  some  places 
the  intima,  in  others  the  adventitia.  The 
capillaries  of  the  glomeruli  are  congested, 
and  the  spaces  about  some  contain  hemor- 
rhagic exudate.  Many  of  the  glomeruli  have 
undergone  sclerotic  changes,  and  are  repre- 
sented by  islands  of  the  firm  fibrous  tissue  in 
which  is  some  hyaline  change. 

The  abscesses  described  in  the  gross  have 
an  inner  layer  of  coagulated  necrosis  and  an 

[41] 


TUBERCULOUS  KIDNEY 

outer  wall  of  firm  fibrous  tissue,  in  which  are 
scattered  a  few  giant  cells.  The  fibrous 
tissue  is  surrounded  by  a  zone  of  hemorrhagic 
exudate  which  infiltrates  the  chronic  inter- 
stitial change  involving  the  cortex.  The 
hemorrhagic  area  in  the  wall  of  the  pelvis 
shows  miliary  tubercles,  round-cell  infiltra- 
tion, edema  and  hemorrhagic  exudate. 

The  patient  reacted  well  from  the  operation 
and  her  post-operative  course  was  uneventful. 

I  was  most  forcibly  struck  by  the  immediate 
and  almost  complete  cessation  of  her  most  dis- 
tressing symptom,  namely,  the  great  urgency 
of  micturition.  After  the  first  twenty-four 
hours,  during  which  time  she  was  catheterized, 
she  was  able  to  hold  her  urine  five,  six  and 
sometimes  seven  hours.  She  enjoyed  for  the 
first  time  in  two  years,  uninterrupted  nights 
of  sleep.  The  point  of  interest  to  be  noted 
here,  is  that  the  irritating  character  of  the 
material  coming  from  the  diseased  kidney 

[42] 


TUBERCULOUS  KIDNEY 

was  the  predominating  causal  factor  of  the 
frequent  urination,  and  not  the  vesical  ulcera- 
tion. The  pain  which  accompanied  urina- 
tion still  exists,  but  is  progressively  decreasing. 

March  6. — Cystoscopy:  The  general  ap- 
pearance of  the  bladder  mucous  membrane 
improved.  The  right  ureteric  orifice  has 
contracted  to  one-half  its  former  size,  no  signs 
of  active  inflammation.  The  ulcers  are 
reduced  to  about  two-thirds  their  former  size, 
their  edges  are  healthy  and  there  is  no 
surrounding  hyperemia.  The  left  ureter- 
mouth  and  surrounding  area  is,  as  before, 
normal,  clear  urine  issues  from  its  mouth. 
The  urine  analysis  gives  no  evidence  of 
kidney  involvement.  The  patient  is  passing 
45  to  55  ounces  of  urine  daily,  at  almost 
normal  intervals  and  in  normal  amounts. 
The  wound  has  healed  but  for  a  small  sinus, 
which  is  progressing  favorably. 

The  patient  is  gaining  weight  and  strength. 

[43] 


TUBERCULOUS  KIDNEY 

She  has   gone  to   country  to  complete  her 
convalescence. 


It  may  be  of  interest  to  add  to  this  report 
of  tuberculous  kidney  that  over  seven  years 
have  elapsed  and  the  patient  continues  in 
good  health.  A  few  other  cases  of  kidney 
tuberculosis  have  fallen  to  my  lot  in  the 
meantime  and  like  the  first  the  symptoms 
have  been  baffling  and  elusive  and  more 
suggestive  of  a  bladder  lesion  than  a  kidney 
involvement.  For  want  of  an  accurate  diag- 
nosis these  poor  sufferers  had  lost  much 
valuable  time  and  received  much  valueless 
treatment. 

In  the  limited  number  of  these  cases  which  I 
have  been  fortunate  enough  to  see  there  has 
been  a  striking  resemblance.  The  difficulties 
in  diagnosis  have  been  somewhat  lessened  by 
improvements  in  the  cystoscopic  apparatus 

[44] 


TUBERCULOUS  KIDNEY 

and  the  methods  of  collecting  and  studying 
the  renal  output. 

After  nephrectomy  all  of  the  cases  which  I 
have  been  able  to  keep  track  of,  except  one, 
have  gone  on  to  a  satisfactory  recovery.  The 
excepted  one  had  ureter  and  bladder  so 
deeply  involved  in  the  process  that  only 
mitigation  of  her  suffering  was  secured. 


[45] 


Ill 


GONOCOCCIC  INFECTIONS,  AND  THE 
PHYSICIAN'S  RESPONSIBILITY 


CHAPTER  III 

GONOCOCCIC   INFECTIONS,   AND   THE   PHYSI- 
CIAN'S  RESPONSIBILITY^ 

This  paper  is  offered  chiefly  as  a  statistical 
study  of  the  more  important  lesions  caused 
by  the  gonococcus,  in  the  hope  of  giving  a 
better  idea  of  the  extent  of  the  disease,  and 
without  attempting  to  teach  anything  of  its 
pathology,  symptomatology,  diagnosis,  or 
treatment. 

The  belief  that  gonorrhea  and  syphilis 
were  but  different  expressions  of  a  single 
disease  held  sway  from  our  earliest  knowledge 
of  the  existence  of  these  diseases,  2,000  years 
before  Christ,  until  the  latter  part  of  the 
eighteenth  century,  when  Benjamin  Bell,  in 
1782,  brought  forward  his  experiments  and 
reasons  for  separating  them.    Again,  in  181 2, 

1  Read  before  the  Westchester  County  Medical  Society,  at 
Yonkers,  November  21,1905. 

4  [49] 


GONOCOCCIC  INFECTIONS 

Hernandez,  by  his  experiments,  tried  to 
demonstrate  their  nonidentity.  The  opinion, 
however,  held  by  these  men  was  not  accepted 
as  final  until,  in  1837-8,  or  within  the  memory 
of  many  now  living,  the  result  of  667  inocula- 
tion experiments  proved  conclusively  the 
nonrelationship  of  these  two  diseases. 

It  remained  for  Neisser,  forty-one  years 
later,  in  the  year  1879,  to  announce  that  he 
had  found  the  specific  organism  of  gonorrhea. 
In  the  two  decades  and  a  half  which  have 
elapsed  since  then  our  knowledge  of  the  far 
reaching  character  of  this  disease  has  made 
remarkable  strides. 

It  was  not  many  years  ago  that  gonorrhea 
was  looked  upon  as  a  local  inflammation 
which  ran  in  the  majority  of  cases  a  mild 
course,  ending  in  complete  cure.  To-day 
we  recognize  in  gonorrhea  a  formidable 
infection  which  has  invaded  practically  every 
tissue  of  the  human  body,  and  from  which  no 

[50] 


GONOCOCCIC  INFECTIONS 

class  of  society  is  immune.  Gonorrhea  is 
said  to  be  the  most  widespread  and  universal 
disease  affecting  the  adult  male  population. 
It  is  estimated  that  75  per  cent,  or  more  are 
infected. 

But  for  rare  exceptions  the  original  site  of 
gonorrheal  infection  in  the  male  is  the 
urethra,  and  from  this  situation  we  may 
follow  its  processes  of  extension  and  com- 
plication. It  remains  for  a  short  period  in 
the  anterior  urethra,  and  in  a  few  instances 
is  cured  without  further  extension.  The 
limitation  of  the  process  to  this  location  (in 
the  absence  of  complications)  offers  the  one 
bright  hope  of  a  definite  cure  and  of  relief 
from  the  uncertainty  of  indefinite  infectious- 
ness to  others. 

Anterior  urethritis  may  be  complicated  by 
balanitis,  cavernitis,  cowperitis,  or  periure- 
thral infiltration  and  abscess,  or  it  may  go 
on  to  stricture  formation.     Of  164  cases  of 

[SI] 


GONOCOCCIC  INFECTIONS 

stricture,  Sir  Henry  Thompson  gives  the 
period  of  development  as  follows:  Ten  cases 
occurred  during  the  acute  gonorrhea;  seventy- 
one  cases  developed  in  one  year;  forty-one 
cases  developed  in  three  to  four  years; 
twenty-two  cases  developed  in  seven  to  eight 
years;  twenty  cases  developed  in  twenty  to 
twenty-five  years. 

Consequent  upon  stricture  there  may  occur 
extravasation  of  urine,  dilatation  of  the 
bladder,  abscess  of  the  prostate,  cystitis, 
pyelitis,  and  pyelonephritis.  With  the  latter 
complications  the  mortality  is  by  no  means 
low.  By  continuity  of  mucous  membrane 
anterior  urethritis  extends  backward  beyond 
the  confines  of  the  compressor  muscle  to 
become  posterior  urethritis. 

In  what  proportion  of  cases  does  gonorrhea 
invade  the  posterior  urethra?  Wossidlo,  of 
Berlin,  quotes  the  following  authors:  Letzel 
gives  it  as  92.5  per  cent.;  Philippson,  86.6 

[52] 


GONOCOCCIC  INFECTIONS 

per  cent.;  Rona,  90  per  cent. ;  and  Jadassohn, 
88.7  per  cent.  This  means  that  almost  nine 
out  of  every  ten  cases  go  on  to  the  occurrence 
of  posterior  urethritis.  The  gravity  of  the 
disease  in  this  situation  is  marked,  not  by  its 
danger  to  the  Hfe  of  the  individual,  or  by  the 
discomfort  and  pain  which  it  occasions,  but 
by  the  danger  of  rendering  him  indefinitely 
infectious  and  perhaps  by  rendering  him 
sterile. 

When  one  considers  the  anatomy  of  the 
posterior  urethra,  its  floor  divided  into  two 
longitudinal  furrows  by  the  caput  gallinaginis, 
on  each  side  of  which  an  ejaculatory  duct  and, 
in  all,  from  twelve  to  twenty  prostatic  ducts 
open,  it  is  not  difficult  to  understand  how 
easily  and  with  what  frequency  the  gonococcus 
invades  the  prostate,  seminal  vesicles,  and 
epididymides.  It  is  equally  easy  to  appre- 
ciate, when  one  thinks  of  the  endurance  and 
long  life  of  these  organisms,  how  it  is  possible 

[53] 


GONOCOCCIC  INFECTIONS 

for  them  to  remain  for  indefinite  periods  in 
these  deeper  structures. 

Many  authorities,  notably  Finger  and 
Frank,  at  present  beheve  the  prostate  to  be 
affected  to  a  greater  or  less  degree  in  practi- 
cally every  case  of  posterior  urethritis,  while 
Guyon  and  Furbringer  do  not  think  it  occurs 
so  often.  According  to  Wossidlo,  Montagnon 
and  Erand  found  the  prostate  involved  in  70 
per  cent,  of  cases  of  posterior  urethritis; 
Colombini,  in  36  per  cent,  of  acute,  28  per 
cent,  of  subacute,  and  40  per  cent,  of  chronic 
gonorrhea.  Pezzoli  gives  80  per  cent,  as  his 
figures.  Rosenberg,  Posner,  and  Goldberg 
join  in  this  estimate  of  its  great  frequency. 
The  varieties  of  prostatitis  we  have  not  space 
to  consider  here. 

That  it  is  a  most  serious  complication  we 
must  take  passing  note  of.  It  is  one  of  the 
chief  phases  of  gonorrhea  which  accounts 
for  chronicity,  resistance  to  treatment,  pro- 

[54] 


GONOCOCCIC  INFECTIONS 

longed  infectiveness,  sexual  neurasthenia, 
sexual  inability,  and  certain  occurrences 
that  take  place  later  in  life. 

As  to  the  frequency  of  spermatocystitis, 
authors  differ.  Wossidlo,  quoting  Guyon, 
Neisser,  Thompson,  Taylor,  Fuller,  and 
others,  says  it  occurs  often.  Fournier  and 
others  maintain  its  rarity.  Lucus  out  of 
285  cases  of  epididymitis  found  in  cases  with 
the  seminal  vesicles  congested.  Colombini 
gave  the  frequency  in  cases  of  epididymitis  as 
62.5  per  cent..  Chute  found,  in  540  patients 
with  affections  of  the  genitourinary  organs, 
that  sixty  had  an  inflammation  of  the  seminal 
vesicles.  The  importance  of  epididymitis  is 
marked  by  its  tendency  to  cause  sterility. 
Finger,  of  Vienna,  gives  the  following  sta- 
tistics of  posterior  urethritis  complicated 
with  epididymitis : 

Rollet  (1862),  2,425  cases,  27.9  per  cent. 
Jullien  (1886),  2,500  cases,  15.2  per  cent. 

1 55] 


GONOCOCCIC  INFECTIONS 

Tarnowsky  (1872),  5,203  cases,  12.2  per  cent. 
Finger,  1,844  hospital  cases,  29.9  per  cent. 
Berg  (1882),  private  practice,  7.5  per  cent. 
Finger,  1,000  clinic  cases,  12.5  per  cent. 
Gilbert  (1893),  650  cases,  7  per  cent. 

Benzler  (1898)  published  the  following 
relationship  between  gonorrheal  urethritis, 
epididymitis  and  sterility: 

Those  rendered  entirely  sterile : 

After  simple  gonorrhea 10.5  per  cent. 

After  one  sided  epididymitis. ...   23 .4  per  cent. 
After  double  epididymitis 42 . 7  per  cent. 

Those  resulting  in  the  "one  child  sterility" : 

After  simple  gonorrhea 17 .3  per  cent. 

After  one  sided  epididymitis. ...   13 . 5  per  cent. 
After  double  epididymitis 20 . 8  per  cent. 

This  study  shows  two  features  of  interest. 
First,  that  there  is  a  considerable  proportion 
of  sterility  following  urethritis  without  appar- 
ent complication,  and,  second,  the  high  pro- 
portion of  sterility  which  follows  epididymitis, 
and  of  the  frequency  of  epididymitis  we  have 
already  spoken. 

[56] 


GONOCOCCIC  INFECTIONS 

Gonorrheal  cystitis  as  a  complication, 
although  not  rare,  is  not  so  frequent  as  it 
was  supposed  to  be  before  the  adoption  of 
the  newer  methods  of  examination,  by  the 
employment  of  which  inflammation  of  the 
bladder  can  be  ascertained  more  exactly. 
Gonorrheal  infection  of  the  ureters,  the  kid- 
neys, and  their  pelves  is  fortunately  a  rare 
occurrence,  although  in  later  life  pyelitis  and 
pyelonephritis  may  follow  upon  the  obstruc- 
tion to  the  urinary  flow  due  to  stricture  of  the 
urethra. 

I  have  attempted  in  a  superficial  way,  and 
omitting  minor  occurrences,  to  give  some  idea 
of  the  frequency  with  which  gonorrhea  occurs 
in  the  male  and  affects  the  different  important 
organs  of  the  male  genitourinary  tract.  In 
order  to  appreciate  the  seriousness  of  this 
malady  one  must  know  something  of  its 
prevalence  as  well  as  of  its  morbid  extension 
in  the  body. 

[57] 


GONOCOCCIC  INFECTIONS 

Our  American  text-books  on  genitourinary 
diseases  give  but  meager  statistical  informa- 
tion regarding  the  frequency  of  this  infection 
and  the  frequency  with  which  individual 
organs  are  affected,  so  that  it  is  little  wonder 
that  the  student  of  medicine  and  the  practising 
physician  often  fail  to  be  impressed  with  the 
magnitude  of  this  evil  and  the  important  racial 
and  social  problems  connected  with  it.  The 
insidious  nature  of  the  gonococcus  and  its  long 
periods  of  symptomless  quiescence  protect  this 
organism  against  discovery  by  those  whose 
minds  have  not  been  trained  to  be  ever  on 
the  alert  for  it,  so  that  those  who  fail  to  appre- 
ciate its  presence  have  no  criterion  upon 
which  to  build  a  theory  that  it  lacks  the 
prevalence  that  careful  clinical  experiences 
have  demonstrated. 

In  concluding  this  chapter  on  the  frequency 
of  gonorrheal  infection  of  the  male  genito- 
urinary system  a  word  must  be  added  regard- 

[58] 


GONOCOCCIC  INFECTIONS 

ing  the  course  the  disease  runs.  For  it  is  due 
to  its  insidious  nature  that  so  many  evil  con- 
sequences arise.  An  initial  attack  of  anterior 
urethritis  without  complication  may  run  its 
course  in  from  four  to  six  weeks.  In  many 
cases,  however,  it  is  much  longer  before  the 
healing  takes  place  and  the  patient  is  appar- 
ently cured.  This  occurrence  is,  unfortu- 
nately, far  from  the  rule,  for,  as  statistics  show, 
the  chances  are  nearly  ten  to  one  that  it  will 
become  a  posterior  urethritis.  With  the 
present  day  treatment  and  intelligent  co- 
operation of  the  patient,  I  believe  we 
should  very  materially  decrease  the  number 

of  cases  that  go  from  anterior  to  posterior 
urethritis. 

When  the  disease  becomes  posterior,  and  we 
have  seen  with  what  frequency  this  occurs, 
the  situation  is  entirely  altered.  It  assumes  a 
gravity  in  its  far  reaching  consequences  to  the 
patient  himself  as  well  as  to  the  community 

[59] 


GONOCOCCIC  INFECTIONS 

that  is  hard  to  reaHze.  It  represents  a  situa- 
tion of  which  the  lay  mind  is  deplorably 
ignorant.  So  deeply  rooted  is  the  traditional 
notion  of  the  insignificance  of  gonorrhea,  and 
so  well  supported  is  this  belief  by  the  absence 
of  pain  or  annoying  symptoms  when  the  dis- 
ease lapses  into  its  "latent"  character,  that 
the  individual  oftentimes  will  not  beheve  that 
the  simple  little  "drop"  which  he  perceives 
in  the  morning  or  the  few  innocent  looking 
"shreds"  which  he  can  see  in  his  urine,  if 
passed  into  a  glass,  may  mean  that  the  wife 
whom  he  marries,  perhaps  years  later,  pays 
for  his  sins  by  receiving  an  infection  that 
may  cost  her  her  life  or  render  her  a  hopelessly 
chronic  invalid. 

But  to  return  to  our  subject,  the  course  run 
by  posterior  urethritis.  It  is  marked  by  its 
chronicity,  its  resistance  to  treatment,  its 
proneness  to  recur,  and  its  uncertainty  of 

definitive  and  permanent  cure.    To  empha- 

[60] 


GONOCOCCIC  INFECTIONS 

size  this,  let  me  recall  to  mind  the  frequency 
with  which  the  gonococcus  invades  the  pros- 
tate gland,  there  to  set  up  a  mild  and  painless 
irritation  or  lie  dormant  for  years,  defying 
oftentimes  the  most  patient,  skillful  and  ex- 
perienced treatment.  M.  von  Zeissl  sums 
up  the  situation  when  he  says  that  every  well 
informed  physician  will  to-day  agree  with 
Ricord,  that  he  well  knows  when  and  how  the 
gonorrhea  began,  but  concerning  its  course 
and  its  cure  it  is  impossible  to  speak  with 
certainty.  As  to  its  infectiveness.  Morrow 
says:  ''Since  no  disease  is  more  surely  trans- 
missible in  the  married  relation  than  gonor- 
rhea, the  man  who  marries  with  an  uncured 
gonorrhea  will  almost  certainly  communicate 
his  disease  to  his  wife." 

I  am  aware  that  I  have  drawn  a  gloomy 
picture  of  gonorrhea  in  the  male,  but  I  have 
tried  to  draw   a  true   one,    taking  for  my 

material  the  figures  and  clinical  experience  of 

[6i] 


GONOCOCCIC  INFECTIONS 

careful  and  conscientious  observers.  Do  not 
draw  the  conclusion  from  what  I  have  said 
that  I  believe  that  all  men  who  have  had  a 
posterior  urethritis  to  be  permanently  infec- 
tious or  that  all  men  will  suffer  in  later  life 
from  their  infections.  There  may  be  some 
who  carry  latent  gonorrhea  into  their  married 
lives  without  infecting  their  wives.  This, 
however,  must  be  very  rare.  On  the  other 
hand,  it  is  not  infrequent,  long  after  an 
apparently  complete  cure,  for  a  man  to  marry 
and  infect  his  wife.  The  following  case  cited 
by  Young  is  an  illustration  of  a  not  uncommon 
occurrence : 

A  man  was  treated  for  three  or  four  years 
by  an  excellent  physician.  He  put  off  his 
marriage  for  two  years  more,  and  finally  the 
physician,  after  examining  carefully  with 
culture  and  cover  glass  preparations,  told 
him  he  could  safely  marry.  Six  weeks  after 
the  wedding  his  wife  was  brought  in  with 

[62] 


GONOCOCCIC  INFECTIONS 

acute  tubal  disease  and  peritonitis  requiring 
laparotomy  and  salpingectomy. 

Besides  the  mucous  membrane  of  the  uro- 
genital tract  that  of  the  nose,  the  mouth,  the 
rectum,  and  all  too  commonly  the  eye,  furnish 
soil  for  the  gonococcus  to  grow  upon.  Of 
gonorrhea  as  a  constitutional  disease  in  both 
sexes  space  does  not  permit  me  to  do  more 
than  speak  briefly.  It  is  a  comparatively  in- 
frequent sequel  to  the  original  mucous  mem- 
brane infection.  That  the  gonococcus  or  its 
toxins  are  conveyed  from  one  region  of  the  body 
to  others  by  means  of  the  blood  or  lymph 
channels  has  been  demonstrated  by  finding  the 
organism  in  the  blood  and  in  the  metastases. 
That  endothelial  and  connective  tissue  struc- 
tures may  harbor  the  gonococcus  we  have  now 
ample  proof.  The  most  frequent  example  of 
general  infection  is  found  in  gonorrheal 
rheumatism,  arthritis  gonorrhoica. 

An  average  of  several  observers  reports  it  as 

[63] 


GONOCOCCIC  INFECTIONS 

occurring  in  slightly  over  2  per  cent,  of  the 
cases.  The  literature  gives  us  examples  of 
gonorrheal  tenosynovitis,  bursitis,  myositis, 
periostitis,  osteomyelitis,  phlebitis,  pleuritis, 
peritonitis,  endocarditis,  pericarditis  and  neu- 
ritis. Gonorrheal  lesions  of  the  skin  have 
been  noted  and  reported. 

The  local  and  systemic  affections  of  chil- 
dren, were  they  considered  in  detail,  would 
fill  a  long  chapter.  It  is  well  known  to-day 
how  gonorrheal  vulvovaginitis  sweeps  as  an 
epidemic  through  the  wards  of  infant  asylums 
and  hospitals.  During  the  year  1902  there 
were  600  admissions  to  the  public  wards  of 
the  Babies'  Hospital  in  New  York,  and  among 
this  number  there  occurred  seventy  cases  of 
vulvovaginitis  and  ten  cases  of  arthritis. 

Stomatitis,  as  a  mode  of  infection,  has  been 
reported  in  a  few  instances.  Urethritis  is  by 
no  means  unusual.  Pelvic  complications  in- 
volving the  uterus,  the  annexa,  or  the  per- 

[64] 


GONOCOCCIC  INFECTIONS 

itoneum  occur  from  time  to  time  in  children. 
Eight  cases  of  gonorrheal  pyemia  without 
discoverable  local  lesion  to  account  for  the 
entrance  of  the  organisms  were  reported  by 
Kimball  in  1903. 

Out  of  58,000  blind  persons,  the  last  census 
of  the  United  States,  Scott  states  that  15,000 
children  lost  their  sight  from  gonorrheal 
ophthalmia.  It  is  said  that  from  20  to  30 
per  cent,  of  all  the  blindness  in  this  country  is 
caused  by  gonorrheal  infection.  A  large 
proportion  of  this  occurs  as  the  result  of 
purulent  conjunctivitis  in  children  infected 
at  birth. 

At  the  present  day  no  one  doubts  that 
gonorrhea  of  the  genitourinary  tract  in 
women  is  a  disease  of  great  frequency.  Fin- 
ger and  others  give  the  following  records  as 
against  Noggerath's  opinion  that  80  per  cent. 
of  all  women  are  affected  with  latent  gonor- 
rhea: Oppenheimer  (1884),  in  Kehrer's 
5  [65] 


GONOCOCCIC  INFECTIONS 

clinic  in  Heidelberg,  examined  io8  pregnant 

women  and  found  the  gonococcus  in  thirty, 

which  is  27.7  per  cent.;  Lomer  (1885),  in 

thirty-two    women    during    the    puerperium 

found  the  gonococcus  in  nine,  or  28  per  cent. ; 

Schwartz  (1886)  examined  617  women,  112 

of  whom  were  suspected  of  gonorrhea,  and  in 

seventy-seven  cases  the  gonococcus  was  found, 

making  12.4  per  cent.;  Sanger  (1889),  in  his 

series  of  1,930  women,  found  230  infected, 

which  makes  12  per  cent. ;  Dorn  (1890),  out  of 

1,000  cases,  found  10.5  per  cent,  of  the  women 

infected;  Sigmund,  of  Vienna,  in  his  venereal 

clinic,  found  that  of  758  public  women,  63 

per  cent,  were  affected  with  gonorrhea. 

The  site  of  election  of  gonococcic  infection 

in  the  female  is  as  follows :  Fabry  (1888)  found 

the  situation  of  gonorrhea    in    thirty-eight 

women  to  be  in  the  urethra  and  cervix  in 

sixteen,  in  the  urethra  alone  in  twenty,  and  in 

the  cervix  alone  in  two;  Welander  (1888) 

[66] 


GONOCOCCIC  INFECTIONS 

found  the  gonococcus  in  the  urethra  in  89  per 
cent,  of  his  cases,  and  in  43.7  per  cent,  in  the 
cervical  canal;  Brlinschke  (1891)  gave  the 
frequency  of  the  situation  of  gonorrhea  as 
90  per  cent,  in  the  urethra,  37.5  per  cent,  in 
the  cervix,  and  12.5  in  Bartholin's  glands. 
Luczny  (1891)  collected  from  Olshausen's 
clinic  forty-seven  cases.  In  this  series  the 
urethra  was  affected  in  forty,  the  vulva  in 
twelve,  Bartholin's  gland  in  seventeen,  and 
the  vagina  in  nineteen  cases. 

This  evidence  points  to  the  urethra  as  being 
the  favorite  site  of  the  original  infection.  In 
just  what  proportion  of  these  cases  the  in- 
fection ultimately  finds  its  way  to  the  cervix 
and  from  thence  to  the  uterus,  tubes,  ovaries, 
and  peritoneum,  it  is  hard  to  say. 

In  what  proportion  of  cases  the  gonococcus 
invades  the  bladder  and  upper  urinary  tract 
it  is  also  impossible  to  say,  but  that  it  is  rela- 
tively infrequent  as  compared  with  the  involve- 

[67] 


GONOCOCCIC  INFECTIONS 

ment   of   the   generative   organs  we  to-day 
know. 

Owing  to  the  different  anatomical  arrange- 
ments and  construction  of  the  genital  organs 
in  the  female  and  the  difference  in  their 
physiological  functions  (menstruation  and 
pregnancy),  the  disease  varies  considerably 
in  its  course,  action,  and  seriousness  from 
that  in  the  male.  The  onset,  the  course, 
and  the  termination  of  female  gonorrhea  is 
so  varied,  the  consequences  to  the  individual 
and  generation  are  so  grave  that  I  hesitate  to 
enter  upon  a  description  that  must  fall  so  far 
short  of  being  complete  in  a  limited  paper  of 
this  kind.  The  majority  of  women  receive 
their  infection  from  an  individual  who  has 
passed  from  the  active  into  the  latent  stage, 
and  whose  gonococci  have  decreased  in  num- 
ber and  to  a  greater  or  less  extent  lost  their 
virulence  by  the  attenuative  influence  of  time 

on  an  impoverished  soil. 

[68] 


GONOCOCCIC  INFECTIONS 

Let  me  illustrate  by  drawing  two  or  three 
typical  pictures.  First,  a  more  unusual  form 
of  the  disease  is  that  of  a  virulent  infection 
with  a  sudden  onset  and  acute  course.  Its 
beginning  is  marked  by  the  appearance  of  acute 
vulvovaginitis  and  urethritis,  with  intertrigo 
from  purulent  secretion,  and  urgency  and 
frequency  of  micturition  set  in.  The  picture 
may  be  complicated  by  an  acute  suppurative 
Bartholinitis.  The  mucous  membrane  of  the 
vulva,  vagina,  and  urethra  are  intensely  red 
and  bathed  in  pus.  With  the  invasion  of  the 
uterus  the  symptoms  of  acute  metritis  appear, 
fever  and  severe  pain  in  the  pelvis  and  across 
the  back,  enlargement  and  exquisite  tender- 
ness of  the  uterus,  with  blood  and  pus  pouring 
from  its  cavity.  The  exudate  extends  into  the 
pelvis  and  around  the  tubes  and  ovaries. 
Pelvic  peritonitis,  it  may  be  general  peritonitis, 
follows.  Salpingitis  and  pyosalpinx  usually 
occur.    The  conclusion  may  be  death  or  a 

[69] 


GONOCOCCIC  INFECTIONS 

capital  operation  or  a  lifetime  of  invalidism 
and  sterility. 

The  second  and  more  usual  type  is  character- 
ized by  a  slow  onset  with  a  chronic  course, 
ready  to  become  an  active  process  through 
the  influences  of  pelvic  congestion  due  to 
excessive  coitus,  menstruation,  or  pregnancy. 
This  form  of  gonorrhea  we  see  most  often  in 
the  young  wife,  married  to  a  man  who  brings 
with  him  an  uncured  gonorrhea.  It  is  more 
than  likely  that  he  is  unaware  of  the  evil  he 
is  doing;  he  may  even  have  the  word  of  his 
physician  that  he  could  safely  marry.  The 
young  and  healthy  woman,  who  never  knew 
what  disturbed  menstruation  or  pelvic  dis- 
comfort was,  begins  soon  after  marriage  to 
ail;  menstruation  may  become  somewhat 
irregular  and  attended  by  increased  secretion 
from  the  genitals.  As  time  goes  on  she 
notices  that  she  becomes  more  easily  fatigued, 
but  she  attributes  these  things  to  the  natural 

[70] 


GONOCOCCIC  INFECTIONS 

changes  that  come  in  newly  married  Hfe  and 
puts  them  from  her  mind .  At  any  time  during 
a  passing  pelvic  congestion,  as  at  a  menstrual 
period,  the  smouldering  infection  may  light 
up  and,  extending  from  its  temporary  resting 
place,  invade  the  uterus.  Here  it  may  pause 
or  continue  on  its  way  until  each  pelvic  organ 
of  generation  participates  and  they  are  all 
matted  into  one  solid  mass  by  the  inflamma- 
tory exudate  surrounding  them.  On  the 
other  hand  this  occurrence  may  not  take  place, 
but  she  may  go  on  to  pregnancy.  This  condi- 
tion is  not  infrequently  interrupted  by  abor- 
tion, or  she  may  be  delivered  at  term,  and  the 
gateways  then  open  for  an  invasion  more 
rapid  and  severe  than  that  we  have  just 
alluded  to. 

Though  the  streptococcus  threatens  life  and 
not  infrequently  causes  death,  it  is,  when  life 
is  spared,  more  merciful.  The  gonococcus 
holds  for  its  victim  a  different  fate. 

[71] 


GONOCOCCIC  INFECTIONS 

With  the  stormy  period  of  the  puerperium 
passed,  the  tedious  convalescence  is  begun, 
holding  in  store  perhaps  a  whole  lifetime  of 
suffering,  intensified  at  each  menstrual  period. 
With  the  hope  of  maternity  blighted,  these 
poor  women  become  nervous  and  hysterical 
wrecks.  By  the  surgeon's  knife  they  may 
get  relief,  but  are  left  castrated  women. 

We  have  seen  in  these  two  types  of  disease  a 
not  unfamiliar  picture,  and  one  in  which  the 
diagnosis  is  usually  plain.  Not  so  obvious, 
however,  are  the  great  majority  of  cases  of 
gonorrhea  in  women.  The  diagnosis,  as  in 
latent  gonorrhea  in  men,  is  difficult,  and 
without  the  microscope  and  culture  tests  is 
in  most  cases  impossible.  Neisser,  in  his 
examination  of  574  public  women,  found  216 
to  have  gonorrhea,  and  out  of  this  number 
there  were  only  twenty-two  in  whom  it  was 
possible  to  make  the  diagnosis  microscopically. 

The  disease,  starting  insidiously,  remains 

[72] 


GONOCOCCIC  INFECTIONS 

latent;  its  course  is  mild,  chronic,  and 
often  without  characteristic  symptoms.  The 
woman  does  not  realize  that  she  harbors  a 
serious  affection.  The  only  symptom  may 
be  a  leucorrhea,  which  disappears  for  a  time 
only  to  reappear.  There  may  be  a  purulent 
discharge  preceding  menstruation  and  fol- 
lowing it.  The  menstrual  function  may  be 
disordered. 

The  great  danger  in  this,  the  commonest 
form  of  gonorrhea  in  women,  lies  in  its  being 
ever  ready  to  extend,  when  a  favorable  oppor- 
tunity offers,  to  the  uterus  and  the  annexa. 
The  consequence  of  this  we  see  in  the  obliter- 
ation of  the  oviduct,  the  deviations  and 
adhesions,  the  suppurative  processes,  and 
peritonitis.  As  to  the  frequency  of  pelvic 
inflammation  due  to  gonorrhea,  statistics  are 
not  satisfactory.  We  can,  however,  arrive  at 
some  estimate  of  its  prevalence. 

Weiss  says  that  salpingitis  as  a  continuous 

[73] 


GONOCOCCIC  INFECTIONS 

infection  occurs  in  from  23  to  70  per  cent, 
of  all  gonorrheas  in  women.  A  percentage 
variously  estimated  at  from  forty  to  eighty  of 
endometritis  and  perimetritis  is  of  gonorrheal 
origin. 

Eighty  per  cent,  of  all  deaths  from  pelvic 
disease  in  women  are  due  to  gonorrhea, 
quoting  Morrow.  Price  said  that  in  over  a 
thousand  sections  for  pelvic  inflammation  95 
per  cent,  of  the  cases  were  attributable  to 
gonorrhea,  and  that  in  95  per  cent,  of  these 
the  history  was  reliable  and  clear. 

As  to  gonorrhea  as  a  cause  of  sterility,  one 
author  states  that  50  per  cent,  of  all  involun- 
tarily childless  marriages  are  made  so  by 
gonorrhea  of  the  female  organs  of  generation, 
of  which  45  per  cent,  are  due  to  marital 
infection  by  men.  On  this  point  there 
seems  to  be  but  little  difference  of  opinion. 
Noggerath  asserted  that  50  per  cent,  of 
sterility  in  women  was  caused  by  gonorrhea. 

[74] 


GONOCOCCIC  INFECTIONS 

Lier-Ascher  found,  out  of  227  women,  121 
sterile  because  of  gonorrhea.  Neisser  con- 
tends that  gonorrhea  is  a  more  potent  factor 
in  the  depopulation  of  countries  even  than 
syphilis.  He  regards  gonorrheal  infection  as 
responsible  for  more  than  45  per  cent,  of 
sterile  marriages.  In  eighty  sterile  marriages 
Kehrer  found  forty-five  caused  by  inflamma- 
tory and  other  changes,  all  of  gonorrheal 
origin.     This  is  upward  of  50  per  cent. 

Janet,  in  1902,  while  discussing  Social 
Defense  Against  the  Venereal  Peril,  declared 
that  gonorrhea  with  tuberculosis,  perhaps 
more  than  tuberculosis,  was  the  great  pest 
of  our  age.  If  we  compare  from  a  social 
point  of  view  the  importance  of  gonorrhea 
with  that  of  syphilis,  gonorrhea  is  to  syphilis 
as  100  is  to  I,  not  only  from  the  standpoint 
of  the  number  of  persons  attacked,  but  also 
from  the  standpoint  of  the  gravity  of  the 
lesions    and    their    perpetuity.     Gonorrhea 

[75] 


GONOCOCCIC  INFECTIONS 

modifies  in  a  manner  often  permanent  the 
genital  organs  of  patients,  renders  them 
infinitely  dangerous  for  the  women  they 
approach,  causes  all  metritides  and  annexial 
inflammations  which  to-day  give  to  surgeons 
three-quarters  of  their  work,  and  conduct 
finally  both  men  and  women  to  sterility. 

It  is  regrettable  that  this  important  matter 
has  received  so  little  attention  in  American 
text-books  of  gynecology  and  genitourinary 
diseases,  and  that  students  of  medicine  should 
start  on  their  career  as  physicians  with  such 
limited  knowledge  regarding  the  extent  and 
consequences  of  this  social  menace. 

I  must  unfortunately  pass  by  that  phase  of 
the  subject  which  has  to  do  with  prostitutes 
and  prostitution  with  but  a  single  remark, 
that  it  is  probable  that  practically  every 
woman  of  this  class,  before  she  has  been  long 

in  the  occupation,  is  gonorrheal  and  a  source 
of  danger.     In  this  class  are  to  be  included 

[76] 


GONOCOCCIC  INFECTIONS 

many  women  working  in  stores,  in  factories, 
as  servants,  or  in  theatrical  companies,  etc., 
who  expose  themselves  to  this  form  of 
infection. 

The  Physician's  Responsibility. — It  may  be 
said,  the  largest,  and  surely  the  saddest,  part 
of  this  great  public  evil  has  its  origin  in  the 
peoples',  our  neighbors',  our  friends',  our 
patients'  ignorance  of  the  subject.  The  only 
key  to  the  situation  is  the  light  of  true  knowl- 
edge, and  the  only  source  at  present  of  this 
light  is  the  medical  profession,  of  which  you 
and  I  are  members. 

BIBLIOGRAPHY 

Bierhoff,  F.  Gonorrheal  Cystitis  in  the  Female. 
Medical  News,  January  12,  1901. 

Casper,  L.    Lehrbuch  der  Urologie,  Berlin,  1903. 

Finger.  Blennorrhoe  der  Sexualorgane.  Handbuch 
der  Urologie,  iii,  part  14.     Wien,  1905. 

Johnson,  J.  F.  Further  Remarks  Upon  Gonorrhea. 
Responsibility  in  Authorizing  Marriage,  New  York,  1904 

[77] 


GONOCOCCIC  INFECTIONS 

Komfeld.    Gonorrhoe  und  Ehe.    Wein,  1904. 

Kimball.  Gonorrhea  in  Infants,  with  a  Report  of 
Eight  Cases  of  Pyemia.  Medical  Record,  November  14, 
1903. 

Keersmaecker  and  Verhoogen.  Chronic  Urethritis, 
New  York,  1901. 

Morrow.    Social  Diseases  and  Marriage,  1903. 

Marshall.    Syphilis  and  Gonorrhea,  1904. 

Noggerath.  Transactions  of  the  American  Gynecologi- 
cal Society,  1877. 

Scott.     Heredity  and  Morals,  1900. 

Sanger.  Die  Trip  per  ansteckung  heim  weiblichen  Gesch- 
lechte,  1889. 

Von  Zeissl.     Diagnose  und  Therapie  des  Trippers,  1903. 

Weiss.     Contributions  to  the  Pathology  and  Treatment 

of  Acute  Gonorrhea.  Medical  News,  September  10— 
17,  1904. 

Wossidlo.     Die  Gonorrhoe  des  Mannes,  1903. 


[78] 


IV 


SOME  NECESSARY  PRINCIPLES  IN  THE 
DIAGNOSIS    OF    SURGICAL    CONDI- 
TIONS  OF  THE  UPPER  URINARY 
TRACT 


CHAPTER  IV 

SOME    NECESSARY   PRINCIPLES    IN    THE    DIAG- 
NOSIS  OF   SURGICAL  CONDITIONS   OF  THE 
UPPER  URINARY  TRACT  ^ 

It  seems  appropriate  just  now  to  group  in  a 
useful  sequence  such  methods,  both  old  and 
new,  as  have  proved  themselves  valuable  in 
making  diagnoses  in  affections  of  the  upper 
urinary  tract.  For  with  the  advent  of  newer 
appliances,  such  as  the  ureter  catheterizing 
cystoscope,  the  various  appliances  for  intra- 
vesical separation  of  the  urine,  and  the  im- 
proved x-ray  apparatus,  there  is  a  tendency 
to  accept  too  confidently  the  evidence  that  any 
one  of  these  instruments  alone  may  give, 
without  giving  due  weight  to  those  prelimi- 

^  Read  before  the  Newark,  N.  J.,  Medical  and  Surgical  Society, 
November  i6.  1905. 

6  [81] 


THE  UPPER  URINARY  TRACT 

nary  steps  in  the  process  of  diagnosis  which 
lead  up  to  the  point  where  these  later  date 
instruments  are  of  real  value. 

Unfortunately  the  idea  is  becoming  prev- 
alent that  urinary  diagnosis  has  become  by 
the  aid  of  mechanical  appliances  a  matter 
both  simple  of  execution  and  rapid  of  com- 
pletion. It  is  true  that,  by  the  added  useful- 
ness of  the  improved  appliances  which  we  now 
have,  diagnoses  are  made  possible  which 
before  were  impossible;  but  it  is  out  of  the 
question  to  hope  to  arrive  at  satisfactory  con- 
clusions in  difficult  cases  without  expense  of 
time  and  study,  both  clinically  and  in  the 
laboratory.  Therefore  those  who  would  look 
for  good  results  in  their  endeavors  to  define 
the  site  and  determine  the  character  of  patho- 
logical conditions  of  the  urinary  system  should 
be  prepared  to  spend  both  time  and  thought  in 
the  elucidation  of  these  problems. 

Before  detailing  an  order  of  procedure  in 

[82] 


THE  UPPER  URINARY  TRACT 

diagnosis,  it  would  be  in  place  to  speak  of  the 
use  of  the  cystoscope,  or  rather  what  has  been 
a  misuse  of  that  instrument.  Knowing  a 
number  of  instances  where  the  ureter  cathe- 
terizing  cystoscope  of  different  makes  and 
varieties  was  used  as  a  universal  instrument 
for  the  exploration  of  the  bladder  as  well  as 
an  aid  to  diagnosis  in  ureter  and  kidney 
affections,  I  was  led  to  further  inquiry,  and 
experienced  the  greatest  surprise  when  I 
learned  from  the  instrument  makers  how 
many  more  ureter  catheterizing  cystoscopes 
were  sold  here  in  America  than  those  of  the 
simple  examining  type. 

A  well-known  firm  in  Berlin,  who  manufac- 
ture the  Nitze  instrument  only,  have  sold  in 
the  United  States  800  ureter  catheterizing 
cystoscopes  and  350  simple  examining  cysto- 
scopes. A  large  importing  and  manufactur- 
ing concern  of  this  city  give  as  their  compara- 
tive sales:  ^^ Three  catheterizing  cystoscopes 

[83] 


THE  UPPER  URINARY  TRACT 

to  one  of  the  plain  examining.''  A  New  York 
house  has,  for  some  six  or  seven  years,  been 
manufacturing'  the  Tilden  Brown  composite 
cystoscope,  which  consists  of  a  common 
sheath  with  telescopic  tubes  for  direct  view 
catheterizing,  and  a  prismatic  telescope  for 
observation.  This  cystoscope  has  not  the 
unpleasant  feature  which  the  prismatic  cathe- 
terizing instruments  have  of  a  shoulder  di- 
rectly behind  the  beak  on  the  shaft.  It  is  only 
within  the  past  year  that  this  company  has 
perfected  the  Otis  cystoscope,  which  is  a 
simple  examining  instrument  of  the  prismatic 
type. 

This  is  certainly  very  suggestive  evidence 
that  a  good  many  physicians  are  buying  and 
using  the  more  complicated  instrument  who 
have  never  learned  to  handle  the  simple  one. 
The  reason  for  this  is  perhaps  not  difficult  to 
explain.  The  recommendation  and  descrip- 
tion by  the  instrument  dealers  of  how  the 

[84] 


THE  UPPER  URINARY  TRACT 

ureter  catheterizing  cystoscope  can  serve  the 
double  purpose  of  exploring  and  catheterizing 
have  led  many  whose  knowledge  of  cystos- 
copy is  mainly  theoretical  to  buy  a  cystoscope 
of  the  catheterizing  variety  without  giving 
the  matter  much  serious  thought. 

The  following  reasons  will  make  evident,  I 
think,  why  the  use  of  the  ureter  catheterizing 
instrument  is  never  justified  until  indication 
for  its  employment  has  been  elicited  by  the 
simple  prismatic  cystoscope. 

First.  From  the  standpoint  of  the  patient's 
comfort,  a  very  important  consideration,  I  be- 
lieve, there  is  no  catheterizing  instrument 
made  that  can  be  introduced  with  as  little 
discomfort  as  any  one  of  several  simple 
examining  cystoscopes  of  prismatic  type, 
averaging  21  by  the  French  scale,  and  with  an 
even,  rounded  shaft,  and  a  gently  angulated 
beak.  All  the  useful  catheterizing  cysto- 
scopes are  considerably  larger  of  caliber,  and 

[85] 


THE  UPPER  URINARY  TRACT 

in  some  varieties  the  shoulder  near  the  beak 
for  the  egress  of  the  catheter  or  catheters  is  an 
added  source  of  discomfort. 

Second,  from  the  operator's  standpoint. 
The  simple  cystoscope  is  more  readily  steril- 
ized. It  is  more  easily  handled  and  intro- 
duced. In  strictured  or  naturally  small 
urethrae  it  is  often  the  only  cystoscope  that  can 
be  introduced.  In  diseased  urethrae,  or 
where  there  is  prostatic  enlargement,  the 
minimum  of  traumatism  is  important.  The 
simple  cystoscope  gives  a  clearer  and  a  larger 
field  of  vision.  It  is  therefore  possible  to 
arrive  at  a  much  more  accurate  interpretation 
of  the  condition  of  the  bladder,  the  state  of 
the  ureteral  orifices,  and  the  character  of  the 
fluid  emitted. 

The  knowledge  gained  by  the  simple  instru- 
ment may  be  sufficient  for  the  diagnosis,  and 
catheterism  of  the  ureters  or  the  use  of  the 

catheter  cystoscope  would  then  be  distinctly 

[86] 


THE  UPPER  URINARY  TRACT 

contraindicated.  It  is  only  in  those  cases 
where  a  ureteral  catheter  has  to  be  employed 
that  we  are  justified  in  the  use  of  the  instru- 
ment for  that  purpose.  Dr.  Max  Nitze,  of 
Berlin,  makes  it  an  unfailing  rule  (where  the 
cystoscope  is  to  be  used)  first  to  explore  the 
bladder  with  the  simple  prismatic  instrument. 
In  the  writings  of  Mr.  Hurry  Fenwick,  of 
London,  the  simple  prismatic  cystoscope 
stands  out  with  such  importance  in  the 
diagnosis  of  kidney  as  well  as  bladder  affec- 
tions, that  one  cannot  fail  to  appreciate  the 
great  value  in  his  hands  of  this  instrument  as 
a  diagnostic  means,  even  to  the  practical 
exclusion  of  the  ureter  catheterizing  cysto- 
scope. If  one  intends  to  do  cystoscopy  and 
hopes  for  good  results  in  this  line  of  work,  he 
will  first  possess  himself  of,  and  learn  to  use, 
the  simple  prismatic  cystoscope. 

A  word  concerning  the  use  of  intravesical 
urine  segregators.    There  are  undoubtedly 

[87] 


THE  UPPER  URINARY  TRACT 

cases  where  these  instruments  can  be  employed 
to  advantage,  but  never  with  that  accuracy 
which  comes  when  the  urine  is  collected 
directly  from  each  ureter  with  a  catheter. 
When  these  instruments  are  used,  it  is  essen- 
tial to  precede  their  employment  by  cystos- 
copy in  order  to  determine  whether  their  use 
is  worth  while,  as  intravesical  enlargement 
of  the  prostate  and  abnormally  placed  ureters 
render  the  instruments  useless. 

Concerning  the  detection  of  calculi  in  the 
ureter  or  kidney,  the  x-rays  are  probably  our 
most  reliable  guide,  but  we  must  be  guarded 
in  our  decisions  about  shadows  lying  in  the 
path  of  the  ureter.  Such  shadows  have  quite 
frequently  of  late  been  seen,  and  an  operation 
been  performed,  no  stone  being  found  in  the 
ureter.  These  shadows  may  be  phleboliths, 
artifacts,  or  sesamoid  bones.  By  introducing 
a  styletted  catheter  into  the  ureter  and  then 
taking  a  radiograph,  we  can  better  determine 

[88] 


THE  UPPER  URINARY  TRACT 

the  situation  of  shadows  that  are  apparently 
those  of  stones  in  the  ureter. 

In  setting  down  the  following  course  of 
procedures  necessary  to  a  diagnosis,  the 
description  of  instruments  and  laboratory 
appliances  and  of  the  technique  used  in  their 
employment  is  purposely  omitted,  in  order 
that  this  paper  may  not  be  too  long. 

Although  it  is  unnecessary  to  enumerate 
here  all  the  surgical  diseases  to  which  the 
kidney  and  ureter  are  liable,  it  is  well  to  men- 
tion the  affections  which  should  always  be 
kept  clearly  in  mind.  Renal  tuberculosis, 
primary  and  unilateral,  perhaps  heads  the 
list  of  those  conditions  which  seem  to  evade 
a  timely  diagnosis.  The  lack  of  patient  and 
repeated  search  for  the  tubercle  bacilli  and 
the  lack  of  proper  diagnostic  measures  must 
be  held  responsible  for  failures  in  diagnosis  in 
the  majority  of  cases.  Pyelitis  and  pyelone- 
phritis, the  variety  of  which  complicates  and 

[89] 


THE  UPPER  URINARY  TRACT 

SO .  often  succeeds  the  infected  bladder,  the 
infection  of  which  is  due  to  urinary  obstruc- 
tion by  prostatic  enlargement  or  strictured 
urethra,  must  be  looked  upon  as  not  uncom- 
mon. Pyonephrosis  is  but  the  terminal  stage 
of  the  preceding  conditions,  plus  a  certain 
number  of  hydronephrosis  in  which  infection 
follows.  Other  forms  of  pyelitis  and  pyelo- 
nephritis are  those  by  infection  upwards,  not 
consequent  upon  an  obstructed  urinary 
flow,  and  those  in  which  infection  occurs 
by  means  of  the  lymph  or  blood  current. 
The  pyelitis  of  pregnancy  should  also  be 
remembered. 

The  Bacillus  coli  communis  is  perhaps  the 
commonest  bacterial  agent.  Pyelitis  due  to 
the  gonococcus  may  be  looked  upon  as  rare. 
It  should  be  remembered  that  the  renal  pelves 
are  made  more  liable  to  infection  by  the 
presence  of  calculi. 

The  diagnosis  of  kidney  stone  is  perhaps 

[90] 


THE  UPPER  URINARY  TRACT 

less  difficult  than  that  of  many  of  the  other 
affections  of  these  organs,  but  nevertheless 
many  mistakes  are  made  in  a  too  hurried 
verdict  on  the  supposed  condition.  Stones  in 
the  ureter  are  looked  upon  as  much  more 
common  than  they  formerly  were,  and  their 
diagnosis  is  certainly  under  better  control. 
The  foregoing  may  represent  the  conditions 
usually  to  be  thought  of  first.  Less  common 
surgical  diseases  of  the  kidneys  are  new 
growths,  cysts,  actinomycosis,  and  injuries 
due  to  external  violence. 

Of  the  ureters,  strictures,  kinks,  and  closure 
of  the  lumen  by  the  presence  of  tumors  are 
conditions  met  with  from  time  to  time. 

When  a  patient  comes  to  us  with  one  or 
more  of  the  following  complaints  or  signs,  we 
naturally  turn  our  attention  to  the  urinary 
system :  Pain  along  the  course  of  the  urinary 
tract;  disturbances  of  the  act  of  micturition; 
pathological  conditions  of  the  urine  evinced 

[91] 


THE  UPPER  URINARY  TRACT 

by   the   presence   of   blood,   pus,    albumin, 
bacteria,  etc. 

The  first  step  should  be  an  explanation  to 
the  patient  of  the  fact  that  in  troubles  of  this 
nature  an  accurate  knowledge  of  the  condition 
is  essential.  In  many  instances  it  requires 
patience  and  time  in  order  to  collect  the  evi- 
dence necessary  for  a  diagnosis.  Preparing 
the  patient's  mind  in  this  way  at  the  outset  is 
much  better  than  promising  an  early  diagnosis 
and  losing  the  patient's  confidence  by  a 
failure. 

It  is  folly  to  give  an  opinion  without  having 
had  sufficient  opportunity  for  observation. 
For  example,  there  are  cases  where  the  finding 
of  the  tubercle  bacilli  must  determine  the 
lesion,  cases  in  which  we  must  repeat  our  in- 
strumental examination,  cases  where  fever  or 
pain  masks  the  evidence  we  seek,  and  cases 
where  the  secretion  of  the  kidneys  change 
from  day  to  day. 

[92] 


THE  UPPER  URINARY  TRACT 

The  history,  both  general  and  urinary,  can- 
not be  too  carefully  taken  and  written  down. 
The  physical  examination  should  be  a  general 
one,  not  focusing  our  attention  too  keenly 
upon  the  urinary  tract  until  we  have  satisfied 
ourselves  as  to  the  patient's  condition  as  a 
whole.  Proceeding  then  to  the  genitourinary 
organs,  if  the  patient  is  a  male,  the  external 
urinary  meatus  is  inspected,  so  that  a  smear 
or  culture  can  be  taken  if  it  is  deemed  neces- 
sary. He  is  then  requested  to  pass  his  urine 
into  two  or  three  glasses.  Immediately  after 
this,  if  the  history  is  suggestive  of  the  presence 
of  residual  urine,  he  is  catheterized  to  deter- 
mine its  amount. 

This  time  for  getting  the  specimens  of  urine 
is  carefully  chosen  before  we  proceed  to  pal- 
pation of  the  kidneys,  ureters,  bladder, 
seminal  vesicles,  and  prostate,  otherwise  the 
evidence  we  seek  from  the  urine,  as  it  is 
usually  passed,  might  be  very  considerably 

[93] 


THE  UPPER  URINARY  TRACT 

changed  by  elements  artificially  expressed 
during  the  palpation  of  these  organs. 

Having  obtained  these  preliminary  speci- 
mens of  urine  we  continue  the  examination  by 
inspection  and  palpation.  We  start  with  the 
kidneys,  ureters,  and  bladder.  Then  the 
external  genitalia  are  examined,  and  finally 
the  rectal  and  bimanual  examination  of  the 
prostate,  seminal  vesicles,  and  bladder  is 
performed.  If  the  patient  is  a  female,  the 
preliminary  specimens  of  urine  can  be  col- 
lected by  the  catheter,  after  which  we  can 
make  the  physical  examination  of  the  urinary 
organs. 

The  next  step  is  determined  by  what  we 
have  already  learned  from  the  history  and 
physical  examination,  plus  what  the  physical, 
chemical,  and  microscopical  examination  of 
the  urine  shows.  If  it  seems  likely  that  one 
or  the  other  kidney  or  ureter  is  involved,  the 
patient's  bladder  is  explored  vrith  the  simple 

[94] 


THE  UPPER  URINARY  TRACT 

prismatic  cystoscope  of  the  plain  irrigating 
type,  as  is  indicated  by  the  presence  or 
absence  of  cloudiness  in  the  urine. 

When  the  patient  is  catheterized  before  we 
fill  the  bladder  for  the  cystoscopy,  this  oppor- 
tunity is  taken  to  obtain  by  sterile  means  urine 
which  can  be  subjected  to  bacteriological 
examination,  if  this  is  necessary. 

By  the  cystoscopic  examination  we  can 
pretty  definitely  determine  whether  the  trouble 
lies  in  the  bladder  or  above,  and  if  the  bladder 
is  not  the  source  of  the  trouble,  we  can  still 
more  definitely  localize  the  disease  by  a  care- 
ful study  of  the  ureteral  mouths  and  of  the 
jets  of  urine  emitted. 

If,  on  the  other  hand,  the  bladder  is  the 
seat  of  the  trouble,  it  will  be  unnecessary  to 
collect  the  separate  urines;  and  in  such  cases 
urinary  separation  and  the  use  of  the  ureter 
catheterizing  cystoscopes  are  contraindicated. 

When  we  have  gotten  evidence  that  the 

[95] 


THE  UPPER  URINARY  TRACT 

lesion  lies  in  the  urinary  tract,  higher  up  than 
the  bladder,  and  if  we  require  for  analysis  the 
secretion  of  the  individual  kidneys,  or  wish  to 
probe  the  ureters  to  determine  their  patency 
or  advance  a  styletted  catheter  to  get  an  :x;-ray 
picture,  we  then  have  the  real  indication  for 
the  cystoscope  which  has  been  especially 
designed  for  catheterizing  the  ureters.  The 
use  of  this  in  the  proper  cases  is  crowned  by 
the  happiest  results. 

After  the  separate  urines  have  been  col- 
lected, the  relative  action  of  the  kidneys  noted, 
and  the  urines  subjected  to  thorough  analysis, 
chemical,  microscopical,  and  bacteriological, 
we  come  to  the  point  where  good  judgment 
and  a  knowledge  of  pathological  anatomy  are 
telling  factors  in  the  summing  up  of  the  evi- 
dence thus  far  obtained.  In  cases  likely  to 
come  to  operation,  steps  to  determine  the 
status  of  the  kidneys  should  be  taken  before 

we  further  consider  nephrectomy. 

[96] 


THE  UPPER  URINARY  TRACT 

It  is  only  by  such  deliberate  and  methodical 
steps  in  history  taking,  in  examination  of  the 
patient,  physically  and  instrumentally,  and  in 
the  complete  analysis  of  the  urine  that  we  may 
hope  to  come  to  a  satisfactory  diagnosis. 


In  reading  this  article  over  in  order  to 
determine  whether  it  shall  be  included  in  this 
publication  or  discarded  because  of  that 
inevitable  rust  which  permeates  our  methods 
and  ideas  of  yesterday,  I  have  decided  that  it 
shall  cast  its  lot  in  with  the  others  chosen, 
and  for  this  reason :  it  presents  a  sequence  in 
the  steps  taken  toward  a  diagnosis  which 
the  experience  of  the  six  years  since  it  made 
its  appearance,  has  emphasized  the  import- 
ance of  making  a  routine. 

A  few  important  items  have  been  added 

to  our  equipment.     The  cysto-urethroscope 

which    makes    simultaneous    inspection    of 

bladder  and  posterior  urethra  possible ;  radio- 

7  [97] 


THE  UPPER  URINARY  TRACT 

graphic  shadows  of  the  urinary  tract  distended 
with  solutions  of  silver  preparations  such  as 
collargol  and  argyrol;  ureteral  catheters  in 
which  a  lead  preparation  is  incorporated; 
also  for  the  purpose  of  the  :r-ray  shadow. 

Of  the  phenolsulphonephthalein  test  men- 
tion has  been  made  elsewhere.  The  older 
models  of  the  catheterizing  cystoscopes  have 
been  much  improved  so  that  to-day  we  have 
an  instrument  the  shaft  of  which  is  uninter- 
rupted by  that  depression  near  the  concavity 
of  the  beak  which  was  a  source  of  discomfort 
and  often  traumatism.  The  irrigating  system 
of  the  newer  instruments  is  easier  of  control 
and  more  efficient. 

When  we  add  these  items  of  recent  acquisi- 
tion to  our  previous  store,  we  find  ourselves 
in  possession  of  considerable  riches  of  diag- 
nostic possibiHties,  when  wisely  employed. 


[98] 


V 
GONORRHEAL  PROSTATITIS 


CHAPTER  V 

GONORRHEAL  PROSTATITIS^ 

The  constancy  with  which  prostatitis  occurs 
when  gonorrhea  invades  the  posterior  urethra, 
and  the  persistent  nature  of  that  inflammation 
after  the  subjective  symptoms,  and  the  more 
evident  of  the  objective  symptoms,  have  sub- 
sided, give  this  condition  the  right  to  more 
consideration. 

That  a  gonorrheal  inflammation  of  the 
posterior  urethra  ever  occurs  without  involv- 
ing the  prostatic  ducts  to  a  greater  or  less 
degree  seems  unlikely.  Anatomically,  there 
is  little  to  invite  a  posterior  urethritis  to  the 
exclusion  of  the  prostate.  The  character  of 
the  epithelia,  the  scarcity  of  mucous  glands, 
and  the  almost  vertical  direction  of  the  canal, 
which  is  distended  so  much  of  the  time  with 

^  Read  before  the  New  York  Academy  of  Medicine  (Section  on 
Genitourinary  Diseases)  November  21,  1906. 

Iioi] 


GONORRHEAL  PROSTATITIS 

urine  and  made  one  with  the  bladder  cavity, 
are  factors  against  a  theory  that  the  prostatic 
urethra  can  be  affected  with  a  gonorrheal 
infection  without  the  prostate  participating. 

Acute  gonorrheal  prostatitis — the  division 
of  this  affection  into  the  catarrhal,  the  foUicul- 
lar,  and  the  parenchymatous  forms — may 
well  be  accepted  as  expressing  the  clinical 
varieties,  providing  the  tendency  of  one  form 
to  merge  into  another  is  appreciated. 

CATARRHAL  PROSTATITIS 

This  form  is  by  far  the  most  frequent  of  the 
acute  varieties.  It  is  highly  probable  that 
with  every  posterior  gonorrhea  there  is  some 
involvement  of  the  prostate  and  though  it 
may  extend  but  a  short  distance  into  the  pros- 
tatic ducts  and  be  relatively  mild,  it  is  obvious 
that  its  existence  should  be  appreciated. 

The  symptoms  of  catarrhal  prostatitis  go 

hand  in  hand  with  the  symptoms  of  posterior 

[102] 


GONORRHEAL  PROSTATITIS 

urethritis — the  increased  desire  to  urinate, 
the  cloudiness  of  both  portions  of  urine,  and 
the  characteristic  small,  round  and  comma- 
shaped  shreds  which  so  often  appear.  These 
filaments,  when  examined  microscopically, 
are  usually  small  plugs  or  casts  made  up  of 
mucus,  pus  cells,  cuboidal  and  cylindrical 
epithelia,  and  gonococci.  The  prostatic  ori- 
gin of  these  shreds  is  not  difficult  to  prove.  If 
after  a  portion  of  the  urine  is  voided  light 
digital  pressure  is  made  on  the  prostate,  the 
shreds  are  squeezed  into  the  urethra  and 
carried  out  with  the  urine  which  is  then  passed. 
The  danger  of  manipulating  the  prostate 
during  an  acute  inflammation  of  that  organ  is 
ever  to  be  borne  in  mind  on  account  of  its 
tendency  to  produce  not  only  an  acute  epidid- 
ymitis but  an  extension  of  the  prostatic  involve- 
ment as  well.  The  clearing  up  of  the  acute 
posterior  urethritis  is,  I  believe,  seldom 
accompanied  with  a  resolution  of  the  catar- 

[103] 


GONORRHEAL  PROSTATITIS 

rhal  prostatitis.    Its  tendency  is  to  go  on  to  a 
chronic  condition. 

The  diagnosis  must  usually  be  made  by  the 
urine,  as  exairdnation  of  the  gland  by  the 
rectum  frequently  fails  to  show  any  change 
in  size  or  consistence  or  give  any  areas  of 
tenderness. 

FOLLICULAR  PROSTATITIS 

This  may  be  an  extension  of  the  catarrhal 
form  or  it  may  follow  directly  the  onset  of  an 
acute  urethritis  posterior.  The  process  of 
mflammation  extends  in  a  selective  way  along 
certain  ducts  toward  the  periphery  of  the 
gland,  and  usually  in  its  upper  part,  there  to 
establish,  by  purulent  or  cystic  distension  of 
the  alveoli,  the  small  nodules  or  tender  areas 
detected  by  digital  examination.  The  symp- 
toms accompanying  this  phase  of  acute 
prostatitis  are  not  unlike  those  of  the  previous 
variety — increased  and  usually  painful  urina- 

[104] 


GONORRHEAL  PROSTATITIS 

tion,  the  pain  intensified  at  the  close  of  the 
act;  both  urines  cloudy;  and  the  comma- 
shaped  shreds,  which  are  seldom  absent. 

Follicular  prostatitis,  like  the  catarrhal, 
tends  to  become  chronic.  The  treatment 
during  the  acute  stage  consists  in  the  treat- 
ment of  the  urethritis,  by  the  avoidance  of 
bodily  exercise,  by  the  avoidance  of  local 
manipulation  of  the  prostate,  and  by  the 
avoidance  of  constipation,  and  the  institution 
of  such  measures  as  will  tend  to  reduce  the 
existing  congestion  and  inflammation. 

PARENCHYMATOUS  PROSTATITIS 

In  its  milder  forms  this  is  clinically  identi- 
fied by  the  hyperemia  or  congestion  of  the 
entire  gland.  By  the  rectum  the  prostate  is 
felt  to  be  evenly  swollen  and  smooth,  and  its 
consistence  is  elastic  or  edematous,  though, 
from  time  to  time,  only  one  of  the  lateral  lobes 
is  found  thus  affected. 

[105] 


GONORRHEAL  PROSTATITIS 

Although  the  organ  is  distinctly  sensitive 
to  pressure  there  is  no  sharp  pain,  but  the 
patient  experiences  a  sense  of  fullness  in  the 
perineum.  Urination  is  made  more  difficult 
and  painful  and  defecation  is  attended  with 
pain  and  discomfort.  There  is  no  fever.  The 
condition  under  appropriate  treatment  may 
subside  in  a  few  days  and  all  subjective  symp- 
toms disappear  or  it  may  go  on  to  chronic 
prostatitis  or  take  on  the  progressive  course 
which  V7e  recognize  as  the  severer  form  of 
parenchymatous  prostatitis,  and  which  at 
times  ends  in  abscess  formation.  Here  we 
find  a  patient  suffering  with  a  painful  sense  of 
pressure  and  swelling  in  the  perineum  and 
rectum.  Micturition  usually  becomes  difficult 
and  painful,  though  in  some  cases  this  is 
absent,  while  in  other  cases  there  is  complete 
retention.  Pain  may  radiate  to  the  glans 
penis,  to  the  thighs  or  across  the  back.  Defe- 
cation may  be  very  painful  and  erections  and 

[io6] 


GONORRHEAL  PROSTATITIS 

pollutions  distressing.  Fever  may  be  present 
and  accompanied  by  chills,  though  Casper 
had  twenty-one  cases  which  went  on  to 
prostatic  abscess,  and  among  them  only  four 
had  a  rise  of  temperature.  On  palpation  the 
neighboring  parts  are  found  extremely  sen- 
sitive, while  the  rectal  examination  of  the 
prostate   is  exquisitely  painful. 

The  gland  is  found  swollen  to  twice  or  four 
times  its  normal  size.  It  feels  hot  and  is  hard 
and  tense,  being  sharply  defined  against  the 
surrounding  softer  structures.  Its  surface  is 
smooth,  seldom  irregular  and  one  side  only 
may  be  affected. 

Notwithstanding  the  severity  of  the  process, 

it  may  not  go  on  to  abscess  formation,  but,  in 

from  one  to  two  wTeks,  the  symptoms  may 

subside   and   resolution   take   place.    This, 

fortunately,  occurs  in  the  larger  proportion  of 

cases,  which  then  go  on  to  a  chronic  condition. 

When  suppuration  does  occur,  the  clinical 

[107] 


GONORRHEAL  PROSTATITIS 

picture  usually  becomes  intensified.  The 
pain  on  urination  is  increased,  ischuria  is 
common  and  the  prostate  becomes  a  pulsating 
and  painful  tumor.  Rectal  tenesmus  is  con- 
stant. The  temperature  rises,  the  tongue 
becomes  dry,  thirst  is  intense  and  the  appetite 
gone ;  headache  and  backache  ensue.  Throm- 
bosis of  the  periprostatic  venous  plexus,  or  in 
the  prostatic  veins  themselves,  may  take  place 
and  go  on  to  a  typical  occurrence  of  pyemia. 
It  is  usually  not  difficult  to  detect  suppuration 
in  the  inflamed  prostate. 

Surgical  interference  is  at  this  moment 
demanded.  If  it  is  delayed,  the  abscess 
usually  empties  itself,  and  most  commonly  into 
the  urethra.  The  urine  then  becomes  loaded 
with  the  products  of  suppuration,  and  the 
fever,  the  dysuria  and  the  rectal  tenesmus 
rapidly  subside.  It  may  be  that  the  evacua- 
tion of  pus  is  incomplete,  and  in  this  instance 
the  disappearance  of  symptoms  is  delayed 

[io8] 


GONORRHEAL  PROSTATITIS 

and  the  process  may  proceed  to  a  chronic 
condition.  Complications,  such  as  infiltra- 
tion of  urine,  gangrene,  chronic  septicemia,  or 
fistula,  at  times  ensue. 

Next  in  frequency  to  the  urethra  as  an  exit 
for  the  pus,  come  the  rectum  and  the  perineum 
in  the  order  given.  In  Segond's  collection  of 
I02  cases,  perforation  occurred  sixty-four 
times  into  the  urethra,  forty-three  times  into 
the  rectum,  fifteen  times  into  the  perineum, 
eight  times  into  the  ischiorectal  space,  three 
times  in  the  inguinal  region,  twice  through  the 
obturator  foramen  and  once  each  through  the 
navel,  through  the  ischiatic  foramen,  at  the 
border  of  a  false  rib,  into  the  abdominal  cavity 
and  into  the  space  of  Retzius.  The  after- 
results  of  prostatic  abscess  may  be  chronic 
suppuration,  neurasthenia,  impotentia  gener- 
andi,  stricture  of  the  rectum,  etc.  It  is  to  be 
borne  in  mind  that  besides  the  complications 

which  not  infrequently  attend  suppurative 

[109] 


GONORRHEAL  PROSTATITIS 

prostatitis  the  mortality  is  considerable.  In 
the  1 02  cases  of  Segond's  referred  to  above, 
there  was  a  34  per  cent,  death  rate.  This  is, 
however,  considered  very  much  too  high 
according  to  other  observers. 

The  treatment  of  these  severer  forms  of 
parenchymatous  prostatitis  is  both  general 
and  local.  The  patient  should  be  put  to 
bed,  a  light  diet  given  and  the  lower  bowel 
kept  empty.  Urinary  antiseptics  should  be 
given  and  warm  applications  or  sitz  baths 
prescribed.  Early  in  the  process  the  direct 
application  of  cold  to  the  prostate  by  means 
of  one  of  the  instruments  designed  for  that 
purpose  is  often  apparently  of  great  benefit. 
The  severer  pain  and  dysuria  must  be  con- 
trolled by  opium  or  its  alkaloids.  A  com- 
plete retention  of  urine  demands  catheteriza- 
tion. With  the  breaking  down  of  the  process 
into  abscess  formation  comes  the  necessity 

for  surgical  relief. 

[no] 


GONORRHEAL  PROSTATITIS 

i 

CHRONIC  PROSTATITIS 

This  condition  assumes  a  degree  of  impor- 
tance which  the  acute  varieties  cannot 
approach.  On  the  score  of  infectiousness 
acute  prostatitis  is  little  to  be  feared,  as  the 
active  and  painful  nature  of  the  condition 
renders  the  individual  practically  incapable  of 
sexual  intercourse.  On  the  other  hand, 
chronic  prostatitis,  which  is  so  often  wholly 
devoid  of  subjective  symptoms,  is  probably  a 
fertile  source  of  the  infection  of  women.  In 
this  connection  it  is  to  be  especially  noted  that 
the  great  majority  if  not  all  of  the  acute 
inflammations  of  the  prostate  pass  on  to  a 
chronic  condition. 

To  divide  chronic  prostatitis,  of  which  the 

chief  etiologic  factor  is  the  gonococcus,  into 

pathological  and  clinical  varieties  is  of  little 

moment.     Clinically,  the  disease  gives  little 

evidence  that  can  be  put  down  as  surely 

[III] 


GONORRHEAL  PROSTATITIS 

characteristic  of  one  or  another  variety,  and 
pathologically  we  usually  find,  in  the  same 
prostate,  changes  belonging  to  various  forms 
of  inflammation.  At  the  same  time  the  fact 
is  not  to  be  overlooked  that  chronic  gonorrheal 
prostatitis  varies  much  in  degree  and  in  resist- 
ance to  treatment. 

Symptoms.  —  The  majority  of  cases  of 
chronic  prostatitis  run  a  mild  course  without 
subjective  symptoms,  the  patients  voiding 
perfectly  clear  urine.  In  others  the  symptoms 
are  so  well  masked  by  the  persistence  of  a 
urethritis  that  a  precise  diagnosis  is  difficult. 
In  the  remaining  class,  however,  some  of  the 
characteristic  symptoms  appear :  Disturbance 
of  urination,  the  changes  in  the  sexual  func- 
tion, abnormal  sensations,  referred  pains, 
neurasthenia,  suffering  from  pains  across  the 
back,  down  the  thighs  or  in  the  testicles,  con- 
stipation, pain  before  and  after  defecation, 
headache  and  mental  depression.    With  some 

[112] 


GONORRHEAL  PROSTATITIS 

patients  frequency  of  micturition,  which  may 
be  attended  with  pain,  is  the  most  prominent 
symptom  and  to  this  may  be  added  the  sense 
of  not  having  completely  emptied  the  bladder. 
With  other  patients  the  disturbances  of  the 
sexual  function  seems  to  stand  out  as  the  chief 
difficulty,  such  as  absence  of  normal  sensation 
at  the  moment  of  ejaculation,  pain  with  the 
seminal  discharge,  distressing  and  persistent 
erections  at  night,  premature  ejaculations  and 
decreasing  sexual  ability.  It  is  in  these  indi- 
viduals that  we  most  frequently  see  the  best 
marked  types  of  sexual  neurasthenia. 

Some  authors  hold  that  prostatorrhea  is  one 
of  the  chief  symptoms  of  chronic  prostatitis. 
The  writer's  experience  coincides  with  those 
who  consider  prostatorrhea  as  an  unusual 
occurrence  in  this  condition.  The  combina- 
tion of  chronic  prostatitis  and  cystitis  is  by  no 
means  uncommon.  In  these  cases  the  treat- 
ment of  cystitis  without  recognition  of  the 
8  [113] 


GONORRHEAL  PROSTATITIS 

prostatitis,  and  attention  to  it,  proves  very 
disappointing. 

All  cases  of  persistent  urethral  discharge 
or  a  persistent  morning  drop  or  those  cases 
with  a  chronic  and  constantly  recurring  dis- 
charge, should  be  suspected  and  examined  for 
prostatitis. 

Diagnosis, — Although  the  subjective  symp- 
toms give  a  valuable  clue  to  the  condition,  an 
exact  diagnosis  cannot  be  made  vdthout  digital 
exploration  of  the  prostate  by  the  rectum  and 
what  is  more  important,  microscopic  examina- 
tion of  the  expressed  prostatic  secretion. 

A  knowledge  of  how  the  normal  gland 
should  feel  in  the  different  periods  of  life  is 
essential  to  the  appreciation  of  size,  configu- 
ration, consistence  and  sensitiveness  of  the 
diseased  organ.  The  changes  in  prostatitis 
noted  by  palpation  are  many.  The  gland  is 
usually  larger  than  normal,  although  this  is 
by  no  means  always  the  case,  for  in  some 

[114] 


GONORRHEAL  PROSTATITIS 

instances  it  is  found  markedly  atrophic. 
Frequently  one  lateral  lobe  only  is  affected,  or 
the  organ  may  be  very  irregular  in  outline  and 
feel  as  though  it  were  made  up  of  many  lobes. 
Modulation  may  be  abundant  or  there  may  be 
but  one  or  two  nodes  and  these  may  vary  in 
size,  consistence  and  location,  but  they  are 
usually  about  the  size  of  a  pea,  hard,  and 
situated  nearer  the  upper  part  of  the  gland. 
The  general  enlargement  of  the  prostate  which 
results  from  a  parenchymatous  prostatitis 
usually  gives  an  edematous  feel  to  the  organ, 
having  lost  its  normal  firm  and  elastic  con- 
sistence, it  becomes,  as  some  authors  put  it, 
flabby,  this  var3dng  much  in  degree. 

The  condition  following  the  follicular  form 
is  varied.  The  gland,  as  a  rule,  is  not  so 
large  as  in  the  post-parenchymatous  condition, 
but  is  usually  harder,  while  here  and  there 
distinctly  soft  spots  may  be  felt  and  the  nod- 
ules are  few  or  many,  localized  or  scattered,  as 

[115] 


GONORRHEAL  PROSTATITIS 

the  case  may  be.  Where  there  has  been  sup- 
puration with  escape  of  the  pus,  involving  the 
whole  gland,  or  one  lateral  lobe,  or  as  in  the 
follicular  variety,  small  areas,  the  character- 
istic changes  of  contraction  and  firm  cicatrices 
result  and  give  that  sense  to  the  examining 
finger.  In  other  cases  there  is  no  change  in 
the  prostate  that  can  be  appreciated  by  digital 
exploration,  and  no  degree  of  sensitiveness;  in 
these  cases  the  diagnosis  depends  alone  on  the 
study  of  the  prostatic  fluid.  Pain  on  palpa- 
tion of  the  prostate  is  generally  a  sign  of  dis- 
ease, but  by  no  means  always,  and  painful 
areas  are  not  infrequently  found  in  prostates 
otherwise  negative  to  the  digital  touch. 

The  secretion  which  is  collected  at  the 
external  urinary  meatus  upon  digital  com- 
pression of  the  prostate,  after  the  urethra  has 
been  cleansed  by  urination  or  irrigation,  con- 
sists normally  of  a  thin,  milky  fluid,  at  times 

slightly  viscid.     Its   specific  gravity  is   but 

[ii6] 


GONORRHEAL  PROSTATITIS 

little  higher  than  that  of  water,  it  is  usually 
faintly  alkaline  to  the  litmus  test,  and  consists 
microscopically  of  lecithin  globules,  varying  in 
size  and  usually  present  in  great  numbers,  and 
epithelia  which  are  partly  cuboidal  and  partly 
columnar.  A  few  leucocytes  are  normally 
present  and  occasionally  some  red  corpuscles. 
Hyaline  bodies  of  considerable  diameter  and 
the  so-called  corpora  amylacea  are  not  infre- 
quently seen. 

The  changes  from  normal  which  most 
commonly  take  place  in  the  prostatic  fluid  are 
in  consistence  and  color.  It  becomes  thicker, 
often  flaky  and  yellowish  or  greenish-yellow 
from  the  addition  of  pus.  Under  the  micro- 
scope there  are  added  to  the  field  of  lecithin 
bodies  pus  corpuscles  in  varying  numbers, 
scattered  or  in  clumps,  depending  on  the 
extent  or  kind  of  inflammation.  In  like  man- 
ner epithelia  from  the  ducts  and  alveoli  are 
added,  and  these  in  different  stages  of  degen- 

[117] 


GONORRHEAL  PROSTATITIS 

eration.  Fat  globules  may  be  seen  free  in  the 
field  or  in  the  epithelia  or  pus  cells. 

The  corpora  amylacea  seem  to  be  much  less 
frequently  seen  in  gonorrheal  prostatitis.  It 
is  to  be  especially  remembered  that  as  long  as 
the  presence  of  pus  cells  can  be  demonstrated 
a  pathologic  condition  exists.  Gonococci 
may  be  found  in  the  pus  cells  and  the  fact 
that  we  cannot  find  them  is  not  proof  of  their 
complete  disappearance. 

Prognosis. — When  is  the  danger  of  infecting 
others  past  ?  When  is  a  chronic  gonorrheal 
prostatitis  cured?  To  these  questions  no 
clean  cut  answer  can  be  given. 

When  the  urine  contains  no  more  shreds  or 

other  abnormal  elements,  and  the  prostatic 

fluid  is  free  from  pus  cells,  and  repeated  search 

for  gonococci  with  the  microscope  and  by 

culture  test  fails,  certainly  we  have  no  grounds 

on  which  to  maintain  that  the  patient  is  still 

afflicted  with  an  infectious  disease.     But  on 

[ii8] 


GONORRHEAL  PROSTATITIS 

the  other  hand,  we  cannot  positively  say  that 
such  individuals  have  become  noninfectious. 

After  a  few  months  or  a  year  we  find,  in  a 
large  number  of  the  cases,  the  presence  of 
gonococci  impossible  of  proof.  Unfortu- 
nately, the  mixed  infection,  which  almost 
always  complicates  these  cases,  renders  the 
task  of  clearing  the  prostatic  fluid  of  pus  cells 
exceedingly  difficult,  if  not  impossible.  Al- 
though it  has  been  stated  that  so  long  as  pus 
cells  remain  a  pathologic  condition  exists,  yet 
experience  has  taught  that  these  cases  are  by 
no  means  always  infectious. 

From  the  observation  of  120  cases,  von 
Notthaf t  has  come  to  the  following  conclusions : 

I .  In  the  second  half  year  after  the  infection 
there  was  73  per  cent,  of  the  cases  in  which  the 
gonococci  could  be  proved  to  be  present  in  the 
prostatic  secretion.  In  the  third  half  year 
this  percentage  fell  to  50,  in  the  fourth  half 
year  to  18,  in  the  third  year  to  6.    From  the 

[119] 


GONORRHEAL  PROSTATITIS 

end  of  the  third  year  no  gonococci  could  be 
found  in  the  prostatic  secretion. 

2.  In  the  second  half  year  there  were  other 
bacteria  besides  gonococci  found  in  the  pros- 
tatic secretion.  In  the  fourth  half  year  there 
were  no  cases  in  which  a  pure  gonococcic 
infection  could  be  demonstrated. 

In  a  few  patients  from  whom  the  writer 
made  cultures  the  results  were  in  accord  with 
Notthaft's  series  so  far  as  mixed  infection  was 
concerned,  but  in  none  of  the  writer's  cases 
were  gonococci  found  by  either  the  micro- 
scope or  culture,  yet  in  five  cases  out  of  the 
eight,  considerably  over  50  per  cent.,  the 
infection  was  less  than  eighteen  months  old. 
In  seven  out  of  the  eight  cases  there  was  a 
growth  of  Staphylococcus  albus,  and  in  two 
of  these  there  was  added  a  growth  of 
Bacillus  xerosis.  In  one  case  there  was  no 
growth. 

The  conclusions  to  be  drawn  are  that  there  is 

[120] 


GONORRHEAL  PROSTATITIS 

difficulty  in  proving  the  presence  of  gonococci 
in  these  older  cases  of  chronic  gonorrheal 
prostatitis,  and  that  other  organisms  play  an 
active  part  in  the  bacteriology  of  this  affection. 

Treatment. — Where  a  urethritis  exists, 
either  anterior  or  posterior,  therapeutic  meas- 
ures designed  for  the  cure  of  this  condition 
must  be  instituted.  For  the  treatment  of  the 
chronically  diseased  prostate,  massage  of  that 
organ  by  the  rectum,  constitutes  the  most 
important  element  of  the  treatment.  The 
bladder  should  be  filled  with  some  such  mildly 
astringent  antiseptic  as  protargol,  1/2  of  i  per 
cent,  solution.  In  very  many  cases  dilatation 
of  the  prostatic  urethra,  either  by  sound  or 
dilator,  is  helpful  in  the  treatment  by  virtue 
of  the  internal  massage  and  stretching  it 
exerts,  especially  on  the  mouths  of  the 
prostatic  ducts. 

Digital  massage,  to  be  useful,  must  be  done 

in    a    systematic    and    purposeful    manner. 

[121] 


GONORRHEAL  PROSTATITIS 

Starting  at  the  external  upper  part  of  the 
lateral  lobe,  the  massaging  finger-tip  works  its 
way  toward  the  median  line  of  the  gland,  again 
it  is  carried  to  the  external  border,  immediately 
below  the  previous  path  of  massage,  and  again 
worked  toward  the  center.  This  is  continued 
until  each  lateral  lobe  has  been  thoroughly 
gone  over.  Then  the  finger  is  swept  over  the 
lateral  lobes  downward  and  toward  the  center, 
emphasizing  the  pressure  brought  to  bear  on 
the  median  line,  that  the  secretion  may  thus 
better  be  expressed  into  the  urethra.  The 
patient  then  voids  the  solution  which  has  been 
left  in  the  bladder,  which  thus  washes  out  the 
urethra  and  comes  in  contact  with  the  recently 
emptied  prostatic  ducts,  which  as  some  think, 
may  take  up  some  of  the  solution  on  the 
principle  of  a  sponge  which  has  been  com- 
pressed and  is  allowed  to  expand  while  in  con- 
tact with  a  fluid.  This  massage  has  two  dis- 
tinctly beneficial  elements.    It  empties  the 

[122] 


GONORRHEAL  PROSTATITIS 

alveoli  and  their  ducts  of  the  perverted  secre- 
tions which  have  accumulated,  and  it  stimu- 
lates a  more  active  circulation  throughout  the 
entire  gland. 

Again  a  warning  against  the  danger  of 
extending  the  process  in  massaging  a  prostate 
in  which  there  still  exists  any  active  inflam- 
mation. 

The  massage  which  is  done  very  gently  at 
first,  should  be  repeated  once,  twice  or  some- 
times three  times  a  week,  depending  on  the 
necessity  of  the  case.  A  few  weeks'  period  of 
treatment  for  the  milder  cases  up  to  many 
months  of  treatment  for  the  severer  cases,  is 
required.  Besides  massage,  such  measures  as 
electricity  or  heat  and  cold  applied  to  the  pros- 
tate may  in  certain  instances  be  helpful. 
Medicinal  suppositories  as  ichthyol,  have  a 
useful  place  in  the  treatment  of  prostatitis. 

The  advancement  of  the  patient's  general 
condition  cannot  be  neglected  and  freedom 

[123] 


GONORRHEAL  PROSTATITIS 

from  worry  or  other  untoward  influences  must 
be  secured.  Favorable  progress  of  the  pros- 
tatitis is  appreciated  partly  by  the  changes  in 
the  gland  felt  by  the  rectum,  but  more  especi- 
ally by  the  study  of  the  prostatic  elements 
microscopically.  Improvement  in  subjective 
symptoms  is  unreliable. 

Although  the  treatment  is  usually  long  and 
trying,  taxing  the  patience  of  the  physician 
and  his  patient,  yet  with  well  directed  and 
conscientious  care  on  the  part  of  the  physician 
and  earnest  cooperation  on  the  part  of  the 
patient,  the  latter  will  be  freed,  in  the  greater 
majority  of  cases,  from  the  danger  of  infec- 
tiousness and  other  consequences  of  chronic 
gonorrheal  prostatitis. 


Since  this  paper  was  written  my  ideas  as  to 
the  treatment  of  chronic  gonorrheal  prostatitis 
have  undergone  some  changes,  until  to-day  I 

find  myself  no  longer  believing  in  the  continu- 

[124] 


GONORRHEAL  PROSTATITIS 

ous  treatment  by  massage,  etc.,  of  these  pa- 
tients. Although  the  mode  of  such  local  treat- 
ment has  not  been  improved  upon,  the  manner 
of  application  has.  At  present  I  find  it  better 
to  give  these  patients  their  treatment  inter- 
mittently— three  or  four  weeks'  treatment, 
then  three  or  four  weeks'  rest.  The  value 
of  promoting  a  cheerful  and  hopeful  frame  of 
mind  and  the  encouragement  of  agreeable 
outdoor  recreation  and  the  establishment  of 
more  normal  ways  of  living  generally,  I  try 
to  impress  upon  my  patients  is  probably  of 
more  value  than  the  local  treatment,  or  in 
other  words,  without  this  general  improve- 
ment in  one's  ways  of  living  the  local  treatment 
is  oftentimes  of  little  or  no  use. 

In  many  of  the  cases  with  long  standing 
disease  and  no  sign  of  improvement  under 
the  foregoing  regime,  nothing  short  of  a 
complete  change  of  living  conditions  is  of 
any  avail  and  these  patients  should  be  sent 

[125] 


GONORRHEAL  PROSTATITIS 

from  the  city  and  put  under  precisely  the 
same  influence  of  environment  as  is  the  tuber- 
culous individual,  if  we  hope  to  arrest  the 
slow  and  insidious  process  of  glandular  de- 
struction and  look  for  a  satisfactory  improve- 
ment and  perhaps  cure. 


[126] 


VI 


COMPARATIVE  VALUE  OF   SOME 
URETHRAL  AND  OTHER  GERMICIDES 


CHAPTER  VI 

COMPARATIVE  VALUE  OF  SOME  URETHEAL  AND 
OTHER  GEEMICrDES^ 

Tece  experiments  conducted  by  Dr.  L.  A. 
Wylie  and  myself  which  form  the  basis  of  this 
contribution  were  done  under  the  kind  direc- 
tion of  Dr.  Charles  Norris,  director  of  the 
pathologic  department  of  Bellevue  Hospital. 

The  method  employed  was  as  follows: 
To  2  c.c.  of  the  various  dilutions  of  antiseptics 
to  be  tested,  were  added  2  c.c.  of  salt  emulsion 
of  the  organisms  used.  It  will  immediately 
be  seen  that  this  procedure  diluted  to  one-half 
the  antiseptic  solution.  To  equalize  this, 
double  the  strength  of  the  antiseptic  solution 
was  used.  The  silver  preparations  were 
bought  in  original  bottles  and  prepared  ac- 

1  Read  before  the  American  Association  of  Genitourinary  Sur- 
geons, New  York,  June  i,  191 1. 

9  [129] 


URETHRAL  AND  OTHER  GERMICIDES 

cording  to  directions.  The  liquor  cresolis 
compositus,  under  the  commercial  name  of 
lysol,  was  from  the  hospital  drug  supply. 

In  the  case  of  each  organism  but  a  single 
strain  was  employed.  Controls  for  each 
organism  were  made  and  the  average  number 
of  colonies,  per  plate,  were  noted.  The  tubes 
in  which  the  bacteria  were  exposed  to  the 
different  solutions  of  the  different  germicides, 
were  left  for  a  period  of  five,  fifteen  and  thirty 
minutes,  respectively.  Then  one  loopful  from 
each  tube  was  mixed  into  a  tube  of  acetic- 
agar  and  poured  into  a  sterile  Petri  dish. 
These  were  incubated  at  37  c.  and  observed  at 
the  end  of  twenty-four  and  forty-eight  hours. 
The  accompanying  results  are  tabulated  after 
the  manner  of  Post  and  NicoU,  whose  tables 
appear  in  The  Journal  of  the  American  Med- 
ical Association,  Iv,  1635. 

In  the  case  of  argyrol,  it  is  to  be  noted  that 
our  results  are  not  in  accord  with  those  of 

[130] 


URETHRAL  AND  OTHER  GERMICIDES 

others  whose  results  we  have  reviewed.    We 
have  no  explanation  for  this  difference. 

It  has  already  been  demonstrated  by  a 
number  of  laboratory  workers  that  the  killing 
power  in  vitro  of  the  several  silver  prepara- 
tions is  weak  or  nil  as  compared  with  the  ac- 
tion of  silver  nitrate. 

It  would  seem  superfluous  to  add  another 
protest  to  the  list  were  it  not  for  the  deep  root 
this  idea  has  taken  that  the  silver  preparations 
hold  some  peculiar  power  not  possessed  by 
silver  nitrate  in  its  various  degrees  of  dilution. 

The  majority  of  these  silver  preparations 
seem  to  hold  a  peculiar  innocuousness  which, 
along  with  their  taking  color  in  solution,  play 
a  part  in  urethral  medication  which  fortu- 
nately interferes  very  little  with  Nature's 
efforts  toward  recovery.  In  fact,  they  have 
constituted  a  means  of  cleansing  the  sur- 
face, of  dilating  the  urethral  canal,  and,  in  the 

case  of  the  more  irritating  members  of  their 

[131] 


URETHRAL  AND  OTHER  GERMICIDES 

large  family,  of  causing  mild  and  transient 
hyperemia,  which  is  a  real  augment  to  Na- 
ture's plan. 

For  the  privilege  of  subscribing  to  their  use 
the  dues  are  about  fifty  times  larger  than 
when  an  equally  efficient  dilution  of  silver 
nitrate  is  chosen.  This  is  a  consideration 
when  suppl3dng  a  large  hospital. 

Bellevueand  AUied  Hospital  spent  last  year: 

For  silver  nitrate $    108.00 

For  coUargolum 25 .00 

For  protargol 224.00 

For  argyrol 910 .  00 

Total $1,267.00 

To  determine  the  power  of  penetration, 
Wildbolz,  of  Bern,  has  done  a  series  of  experi- 
ments with  silver  nitrate  and  protargol  on  the 
living  mucous  membranes  of  the  eye  and 
urethra  in  dogs — a  reduction  of  the  silver 
being  accompHshed  by  exposure  to  a  Finsen 
light.    In   the   urethra   he   used    1:1000   to 

[132] 


URETHRAL  AND  OTHER  GERMICIDES 


i:ioo  silver  nitrate  and  i  per  cent,  to  3  per 
cent,  protargol  solutions.  There  was  some 
penetration  of  the  metal  down  to  the  subepi- 
thelial tissue.  In  penetrating  power,  the 
silver  nitrate  easily  predominated. 

NUMBER  OF  COLONIES  IN  ONE  LOOPFUL  TEST  SOLUTION 
AFTER  TWENTY-FOUR  HOURS'  INCUBATION 

S  15  30 

Solution  Organism        Min.       Min.       Min. 

Argyrol 30  per  cent.  Strep o             o             o 

"                    30  per  cent.  Staph o             o             o 

"                    30  per  cent.  B.  coli 000 

"                    30  per  cent.  Gon 70           50           10 

"                    10  per  cent.  Strep 400 

"                    10  per  cent.  Staph o             o             o 

"                     10  percent.  B.  coli 000 

'*                    10  per  cent.  Gon 90           70           50 

"                      I  per  cent.  Strep 50           35           35 

I  percent.  Staph 100           75         100 

I  per  cent.  B.  coli iiSoo         500         100 

"                      1  percent,  Gon 120           50           25 

Protargol 10  per  cent.  Strep....,,...  25  20  20 

10  per  cent.  Staph. .......  100  1  75 

"                    10  per  cent,     B.  coli 000 

10  per  cent.     Gon 30  15  25 

"                      S  percent.     Strep 49  31  26 

5  per  cent.     Staph 150  50  50 

"                       5  percent.     B.  coli o  100  25 

[^33] 


URETHRAL  AND  OTHER  GERMICIDES 


Solution 
Protargol  .  . 


Silver  nitrate. 


.  5  per  cent. 
I  per  cent. 
I  per  cent. 
I  per  cent. 

1  per  cent. 

.    2  per  cent. 

2  per  cent. 
2  per  cent. 
2  per  cent. 
I  per  cent. 
I  per  cent. 
I  per  cent. 
I  per  cent. 

1/2  per  cent. 

1/2  per  cent. 

1/2  per  cent. 

1/2  per  cent. 
I  to  1,000 
I  to  1,000 
I  to  1,000 
I  to  1,000 
I  to  5,000 
I  to  5, 000 
I  to  s.ooo 
I  to  s.ooo 
I  to  10,000 
I  to  10,000 
I  to  10,000 
I  to  10,000 


5 

Organism  Min. 

Gon 90 

Strep 48 

Staph 00 

B.  coli 1,000 

Gon 100 

Strep o 

Staph o 

B.  coli o 

Gon o 

Strep 6 

Staph o 

B.  coU 10 

Gon o 

Strep 10 

Staph o 

B.  coli 100 

Gon o 

Strep IS 

Staph 7 

B.  coli 600 

Gon o 

Strep 23 

Staph 10 

B.  coli 1,000 

Gon o 

Strep 44 

Staph 22 

B.  coli 00 

Gon S2S 


IS 

30 

Min. 

Min. 

SO 

35 

44 

39 

200 

150 

700 

200 

35 

25 

0 

0 

0 

0 

0 

0 

0 

0 

5 

0 

0 

0 

IS 

SO 

0 

0 

8 

0 

0 

0 

36 

10 

0 

0 

70 

6 

14 

5 

500 

300 

0 

0 

40 

IS 

6 

3 

S.ooo 

S.ooo 

0 

0 

26 

SO 

5 

3 

00 

00 

40 

20 

[134] 


URETHRAL  AND  OTHER  GERMICIDES 


5 

Solution                                        Organism  Min. 

Cresol  Comp....   lo  per  cent.  Strep o 

lo  per  cent.  Staph o 

lo  percent.  B.  coli o 

lo  per  cent.  Gon o 

S  per  cent.  Strep o 

5  per  cent.  Staph o 

5  per  cent.  B.  coli o 

5  per  cent.  Gon o 

2 . 5  per  cent.  Strep o 

2 .  s  per  cent.  Staph 5 

2  . 5  per  cent.  B.  coli o 

2.S  per  cent.  Gon o 

1 . 2  per  cent.  Strep o 

1 . 2  per  cent.  Staph 4 

1 . 2  per  cent.  B.  coli 200 

1.2  per  cent.  Gon 550 

o .  s  per  cent.  Strep 3 

0.5  per  cent.  Staph 8 

o .  5  per  cent  B.  coli CXD 

0.5  per  cent.  Gon 600 

CoUargolum.. .   2.5  per  cent.  Strep 15 

2 . 5  per  cent.  Staph 15 

2 .  s  per  cent.  B.  coli o 

2 . 5  per  cent.  Gon 80 

1.25  percent.  Strep 25 

1.25  per  cent.  Staph 00 

1. 25  percent.  B.  coli o 

1.25  percent.  Gon 120 

Cargentos ....     20  per  cent.  Strep o 

"                    20  per  cent.  Staph 7 

[135] 


IS 

30 

Min. 

Min. 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

300 

0 

0 

0 

0 

0 

40 

16 

500 

100 

8 

0 

I 

0 

0 

0 

100 

15 

12 

10 

100 

100 

100 

100 

100 

75 

0 

0 

0 

0 

URETHRAL  AND  OTHER  GERMICIDES 

5  IS  30 

Solution  Organism        Min.       Min.       Min. 

Cargentos  i  i  . . ;  20  per  cent.  B.  coli o  o  o 

"  20  per  cent.  Gon 18  10  o 

"  5  per  cent.  Strep 28  20  15 

"  5  per  cent.  Staph 50  2  20 

"  5  percent,  B.  coli 000 

"  5  percent.  Gon 75  o  50 

00=  Infinite  number  of  colonies  per  plate. 

As  to  the  value  of  antiseptics  penetrating 
below  the  surface:  In  order  to  check  up  the 
work  of  other  experimenters,  Derby,  of 
Boston,  made  a  series  of  observations  as 
follows:  He  took  samples  of  sterile  hydrocele 
fluid  and  bovine  serum;  to  i  c.c.  of  the  serum 
he  mixed  i  c.c.  of  the  silver  preparation  to  be 
tested  and  to  this  he  exposed  the  staphylococ- 
cus. The  nitrate  of  silver,  2  per  cent., 
showed  a  growth  of  the  organisms  after  an 
exposure  of  from  thirty  to  forty  minutes;  the 
protargol,  8  per  cent.,  after  sixty  minutes;  the 
argyrol,  50  per  cent.,  gave  an  abundant 
growth  after  three  and  one-half  hours.  Other 
.  preparations  showed  the  same  results. 

[136] 


URETHRAL  AND  OTHER  GERMICIDES 

This  goes  to  show  how  completely  the  body 
fluids  can  destroy  the  bactericidal  power  of 
antiseptics  when  brought  into  contact  with 
them,  and  how  little  advantage  there  can  be 
in  a  drug  having  the  power  to  penetrate  below 
the  surface. 

Literature 

1.  G.  S.  Derby.  "An  Experimental  Study  on  the 
Bactericidal  Process  of  Various  Silver  Preparations." 
Boston  M.  andS.  Journal,  1906-clv.  341-343. 

2.  Muller.  ''Ein  Kleiner  Beitrag  zum  Kenntniss  der 
Wirkung  der  Silber  verbindungen."  Berlin  thierarztl, 
wchnschr,  1902,  page  267. 

3.  W.  A.  Puchner.  *'The  Chemistry  of  the  Organic 
Silver  Compounds."  A.  M.  A.  Journal,  Chicago,  1906, 
xiv,  II,  1256. 

Professor  of  Chemistry,  University  of  111.  School  of 
Pharmacy,  Chicago. 

4.  H.  Wildbolz.  "Experimentelle  Untersuchingen  uber 
die  Wirkung  von  Silber  Nitrat  und  Protargollosungen  auf 
labende  Schleimhaute."  Ztschr.  f.  Urolog.,  Berlin  v. 
Leipz,  1907,  185,  200. 

5.  E.    B.    Cragin.     ''The  Prophylactic  and  Curative 

[137] 


URETHRAL  AND  OTHER  GERMICIDES 

Treatment  of  Ophthalmia  Moenatonun."  Journal  of 
Surgery,  Gynecology  and  Obstetrics,  1907. 

6.  J.    Burdon  Cooper,  M.  D.  B.  S.,  BSc,  F.  R.  C. 

S.  S.  E.  "Argyroris,  Including  a  Preliminary  Note  on  the 
Action  of  Silver  Salts."     Ophthalmoscope,  1907,  page  i6_ 

7.  Lohnstein.  "Experimentelle  Unterzuchen  uber  die 
Wirkung  einiger  Silberpraparate  auf  die  Harnrohre  des 
Kaninchens."     Monatsberichte  f.  Urologie.  Bdg.,  1904. 

8.  Post  and  NicoU.     "The  Comparative  Efficiency  of 
Some  Common  Germicides."     A.  M.  A.  Journal,  Nov 
5th,  1910,  vol.  Iv. 

9.  Anderson,  J.  F.  and  McClintic,  T.  B.-  "A  Method 
for  the  Bacteriological  Standardization  of  Disinfectants.' 
Jour.  Infect.  Dis.,  January  3,  191 1. 

10.  Phelps,  EarleB.-  "The  Application  of  Certain  Laws 
of  Physical  Chemistry  in  the  Standardization  of  Disin- 
fectants."    Jour.  Infect.  Dis.,  January  3,  191 1. 

11.  Kendall,  A.  E.  and  Martin,  Edw.  "A  Method  for 
Determining  the  Germicidal  Value  and  Penetrating 
Power  of  Liquid  Disinfectants."  Jour.  Infect.  Dis., 
March  6,  1911. 

12.  Rideal,  S.  and  Walker,  J.  S.  A.  Jour.  Royal 
London  Inst.,  London,  1903. 

13.  Chick,  H.,  and  Martin,  C.  J.  Journal  Hyg.j 
London,  Nov.,  1908. 

[138] 


VII 

ON  WHAT   IS  NEW  IN   GENITOURINARY 
SURGERY 


CHAPTER  VII 

ON  WHAT  IS  NEW  IN  GENITOURINARY  SURGERY 

For  recent  attainments  in  this  department  of 
medicine  the  pubHc,  at  large,  though  it  is  not 
Hkely  to  know  it,  has  reason  to  be  grateful, 
for  they  deal  in  the  main  with  what  is  practi- 
cally the  most  important  function  of  the 
physician — that  of  diagnosis. 

This  little  book  being  in  no  sense  a  text- 
book the  reference  to  what  is  new  will  be  but 
tersely  given;  merely  that  the  progress  in 
this  branch  of  work  may  be  remarked. 

Appended  to  some  of  the  essays  mention  has 
been  made  or  short  descriptions  given  of  such 
of  the  newer  methods  or  appliances  as  would 
help  to  bring  the  subjects  dealt  with  up-to- 
date,  they  will  on  that  account  be  omitted 

here. 

[141I 


GENITOURINARY  SURGERY 

The  intra-vesical  treatment  of  papillomata 
by  means  of  a  high  frequency  current  spark 
has  arrested  the  attention  of  the  genito- 
urinary surgeon — and  wisely,  for  the  results 
of  the  cutting  operation  for  these  growths 
has  been  far  from  satisfactory  owing  to  the 
frequency  of  their  recurrence  and  the  alarming 
percentage  of  their  malignancy.  The  appli- 
cation of  the  high  frequency  (Oudin)  current 
spark  to  these  tumors  is  a  simple  procedure 
carried  out  by  passing  the  insulated  wire 
through  the  catheter  canal  of  a  cystoscope 
and  the  growth  thus  cauterized.  The  opera- 
tion causes  little  or  no  more  discomfort  than 
an  ordinary  cystoscopy  for  ureter  catheteri- 
zation and  one  to  three  or  four  applications 
of  a  few  seconds  to  a  few  minutes  has  been 
sufficient  in  the  majority  of  cases  thus  far 
reported  to  effect  a  complete  disappearance 
of  the  tumor.    Although  the  cases  have  been 

too  few  and  the  time  too  short  to  speak 

[142] 


GENITOURINARY  SURGERY 

definitely  as  to  the  permanency  of  the  cure 
two  things  are  certain,  a  major  operation 
under  general  anesthesia  is  avoided  and  there 
is  no  bladder  scar  to  invite  a  recurrence. 

It  would  seem  unnecessary  to  add  that  the 
most  promising  results  are  to  be  expected 
from  young  growths  not  deeply  rooted.  In 
this  connection  it  might  be  said  to  those 
who  have  an  eye  open  for  urinary  ills,  verbum 
sat  sapienti.  For  this  mode  of  treating 
bladder  tumors  we  are  indebted  to  Edwin 
Beer,  of  New  York. 

When  the  news  of  a  complement-fixation 
test  for  the  diagnosis  of  gonococcic  infections 
made  itself  heard,  there  was  reason  for 
rejoicing,  even  before  it  was  proved  to  be  of 
any  value  there  was  reason  for  rejoicing,  for 
here  was  evidence  of  serious  thought  and 
scientific  interest  being  bestowed  on  this  dis- 
dained and  neglected  diplococcus.  It  is 
hardly  a  year  since  Schwartz  and  McNeil 

[143] 


GENITOURINARY  SURGERY 

published  their  experiments  applying  the 
complement-fixation  test  to  324  human  sera. 
The  results  of  these  experiments  give  promise 
of  much  needed  aid  in  the  diagnosis  of  certain 
chronic  gonococcic  infections,  the  very  cases 
in  which  we  are  in  most  need  of  more  definite 
data,  in  order  to  afifirm  or  dispel  the  fear  of 
the  lingering  infection. 

The  subject  of  the  treatment  of  gonococcic 
infections  with  vaccines  or  bacterins  is,  as 
yet,  not  concluded.  Painstaking  work  is 
still  beiag  pushed  along  this  fine,  but  at 
present,  with  the  possible  exception  of  the 
joint  cases,  there  is  little  definite  evidence  to 
encourage  the  thought  that  a  distinctly  useful 
means  of  therapy  has  been  found. 

The  last  six  or  seven  years'  trial  of  tuber- 
culin in  genitourinary  tuberculosis  has  light- 
ened the  burden  of  prognosis  encouragingly. 

In  the  shortness  of  this  chapter  no  injustice 
to  the  subjects  has  been  intended;  they  are  too 

[144] 


GENITOURINARY  SURGERY 

important  to  be  but  partially  described;  to 
have  dealt  in  detail  with  them  would  have 
carried  this  small  volume  beyond  its  design, 
therefore,  they  have  been  but  mentioned. 


10  [145] 


VIII 

IS  GENITOURINARY  SURGERY  JUSTIFIED 
AS  A  SPECIAL  BRANCH  OF  MEDICINE? 


CHAPTER  VIII 

IS   GENITOURINARY   SURGERY  JTJSTIEIED  AS  A 
SPECIAL  BRANCH  OF  MEDICINE? 

The  extent  to  which  medical  knowledge  has 
grown  has  forced  a  division,  for  the  sake  of 
progression  and  administration,  of  that  knowl- 
edge; yet  we  still  remain  saddled  with  an 
awkward  problem. 

That  which  constitutes  a  specialty  and  that 
which  justifies  it  are  two  different  things ;  yet 
they  are  in  very  close  relation.  The  clear 
definition  of  what  any  special  branch  of 
medicine  consists  is  essential  to  the  life  of 
that  special  branch.  The  justification  of 
any  special  branch  of  medicine  is  its  results 
as  an  organized  body  in  a  special  field. 

If  any  general  surgeon  can  prepare  himself 
to  treat  flat  feet  as  well  as  the  orthopedic 

[149] 


GENITOURINARY  SURGERY 

surgeon,  it  makes  very  little  difference  to  the 
department  of  orthopedic  surgery;  but,  if 
the  department  of  general  surgery  prepares 
itself  as  a  body  to  treat  flat  feet  as  well  or 
better  than  the  orthopedic  surgeons  can,  the 
orthopedic  surgeons  are  threatened  with  the 
loss  of  their  flat  feet — and  justly. 

This  hints  an  analogy  to  the  genitourinary 
surgeon  if  he  would  have  his  specialty  justified 
as  a  distinct  entity.  If  the  genitourinary 
surgeons  lack  the  opportunity  of  being  equally 
skilled  in  the  major  operating  pertaining  to 
their  special  field  with  those  in  other  fields 
who  include  portions  of  the  genitourinary 
system  with  their  own  work,  would  not  an 
extension  of  the  genitourinary  work  into  other 
fields  of  labor  be  advisable  ? 

If  it  is  going  to  be  to  the  best  advantage  of 
patients  to  have  their  kidneys,  ureters  or 
bladder  operated  upon  by  the  general  surgeon 
or  gynecologist  then  the  question  of  whether 

[150] 


GENITOURINARY  SURGERY 

genitourinary  surgery  is  justified  as  a  specialty 
can  be  promptly  answered  in  the  negative. 
One  thing  cannot  be  lost  sight  of:  if  scientific 
advancement  is  to  be  a  consideration,  the 
responsibility  of  such  refinement  of  diagnosis 
as  is  obtainable  to-day  must  fall  upon  who- 
ever essays  to  bring  these  cases  to  their  logical 
conclusion.  There  is  one  more  thing  which 
is  of  especial  interest  to  the  patient  in  this  con- 
nection and  which  cannot  be  lost  sight  of — 
that  is  the  many  cutting  operations  which 
have  been  entirely  obviated  by  the  use  of 
various  cystoscopes,  cautery,  ureter  catheters, 
functional  kidney  tests  and  other  bladder  and 
urethral  instruments  in  the  hands  of  those 
trained  in  this  work. 

The  situation  of  the  gynecologist  here  in 
this  country  has  an  interesting  relationship  to 
this  problem.  As  a  body  they  are  without 
the  diagnostic  training  in  the  urinary  system 
to  justify  their  including  the  urinary  organs 

[151] 


GENITOURINARY  SURGERY 

in  their  special  field  of  work.  In  consequence 
of  this  the  genitourinary  surgeon  finds  he  has 
much  to  do  with  the  female  urinary  tract ;  and 
much  of  his  operative  work  falls  in  this  field. 
In  consequence  of  these  things  would  it  be 
strange  if  genitourinary  surgery  came  to  in- 
clude the  genital  as  well  as  the  urinary  organs 
of  both  sexes?  Would  not  this  help  in  the 
general  advancement  of  the  cause  as  well  as 
lend  a  broadening  effect  to  the  character  of 
surgical  work  as  a  whole  ? 

If  the  situation  of  American  gynecology  to- 
day holds  an  interesting  relationship  to  genito- 
urinary surgery,  the  position  of  general  sur- 
gery in  this  relation  is  even  more  interesting; 
for  here  we  have  a  large  class  of  the  medical 
profession,  so  many  of  whom  are  frankly  in- 
cluding the  surgical  care  of  the  genitourinary 
organs  in  their  field  of  work;  without  appar- 
ently seeking  to  avoid  the  many  costly  errors 
which  arise  from  the  lack  of  training  neces- 

[152I 


GENITOURINARY  SURGERY 

sary  to  the  accurate  diagnosis  of  diseases  of 
these  organs;  which  they  profess  themselves 
capable  of  caring  for  to  the  best  interests 
of  their  patients. 

The  foregoing  but  reflects  a  feeling  and 
speaks  a  healthy  discontent — looking  to  bet- 
ter things. 

One  thing  seems  certain,  that  conditions 
are  breeding  a  larger  type  of  man  for  genito- 
urinary surgery ;  and  there  is  little  doubt  that, 
with  the  broader  education  of  the  medical 
profession  to  the  rapid  advance  in  genito- 
urinary surgery  in  the  past  ten  or  twelve  years, 
the  up-to-date  hospitals  in  the  larger  cities 
will  see  to  it  that  there  is  a  department  and  a 
provision  of  beds  for  the  proper  study  and 
care  of  these  cases. 

To  gain  a  moment's  detachment  from  that 
narrower  viewpoint  which  is  apparently  but 
looking  to  the  advance  of  but  a  part  of  the 
whole,  will  perhaps  be  helpful. 

[153] 


GENITOURINARY  SURGERY 

It  was  not  so  very  long  ago  that  the  practice 
of  the  art  of  medicine  was  but  a  one  man's 
task.  All  that  was  useful  of  medical  knowl- 
edge could  be  carried  in  one  man's  brain.  All 
that  was  necessary  for  technical  application 
could  be  mastered  by  one  man's  skill.  This 
meant  a  coordination  of  the  parts  of  that 
knowledge  with  a  single  administration  centre. 
The  result  meant  a  minimum  loss  of  energy 
and  the  strength  of  such  a  position  can  only 
be  appreciated  by  comparing  it  with  the  state 
of  affairs  which  exist  in  medicine  to-day. 
Could  we  but  possess  an  appreciable  some- 
thing which  could  be  called  a  unit  of  medical 
energy,  by  such  a  measure  we  could  draw  a 
graphic  picture  of  the  loss  that  has  been 
suffered  by  the  splitting  up  of  medical  knowl- 
edge and  the  disappearance  of  an  adminis- 
trative head. 

This  brings  us  face  to  face  with  perhaps 
the  most  important  problem  of  the  medical 

[154] 


GENITOURINARY  SURGERY 

profession  of  to-day.  The  splitting  up  of 
medical  knowledge;  the  establishment  of 
separate  branches  of  that  knowledge  we  know 
were  inevitable  steps  in  the  evolution  of  this 
branch  of  learning;  but,  to  have  lost  our 
head  should  not  have  been  included  in  the 
process.  The  present  transition  stage  of 
urban  medicine  might  almost  be  likened  to 
a  river  flowing  backward;  draining  an  ocean 
of  knowledge  and  disappearing  in  rivulets, 
with  the  public  bathing  in  the  intermediate 
marshes  of  chicanery. 

If  the  medical  profession  is  to  be  useful  to 
the  public  for  whom  it  is  designed;  in  pro- 
portion to  the  treasures  of  its  present  knowl- 
edge and  skill;  it  will  have  to  administer  this 
knowledge  by  means  of  harmonious  groups  of 
its  individual  members,  brought  together  so 
as  to  represent  the  sum  of  its  attainment. 

Until  this  time  comes  the  justification  of  any 
special  branch  of  medicine  or  surgery  must 

[155] 


GENITOURINARY  SURGERY 

be  according  to  such  good  results  as  our 
present  inadequate  system  of  independent 
specialties  is  able  to  show. 


[156] 


IX 
THE  BY-WAYS  OF  PROSTATECTOMY 


CHAPTER  rX 

THE  BY-WAYS   OF  PROSTATECTOMY 

Prostatectomy  is  a  live,  up-to-date  subject, 
even  though  it  deals  with  the  decadent  end  of 
human  existence,  and  although  our  present 
age  is  sometimes  called  a  commercial  age,  it 
has  not  in  the  slightest  deterred  the  progress 
of  the  surgeons'  art  in  this  direction. 

The  argument  as  between  ''catheter  life" 
and  prostatectomy  in  the  majority  of  cases 
has  sunk  to  almost  nothingness  in  favor  of 
the  latter.  The  worthiness  of  relieving  these 
aged  sufferers  of  their  pelvic  predicament  by 
removal  of  the  prostate  seems  pretty  well 
proven,  even  after  discounting  the  statistics 
compiled  from  carefully  selected  cases. 

Whatever  may  be  said  against  the  method 
so  much  in  vogue  to-day  of  adopting  for  one's 

[159] 


BY-WAYS  OF  PROSTATECTOMY 

own  use  some  one  of  the  several  ways  of 
prostatic  removal  to  the  exclusion  of  all  other 
forms  of  the  operation,  there  is  this  to  be  said 
most  emphatically  in  its  favor — that  it  tends 
to  give  the  operator  the  faculty  of  reducing 
traumatism  and  time  to  the  minimum.  In 
hardly  any  other  operation  in  surgery  is  the 
importance  of  this  so  distinct.  It  cuts  to 
the  narrowest  limits  for  these  aged  patients 
the  period  of  anesthesia,  the  amount  of 
bleeding  and  the  degree  of  surgical  shock. 

It  is  not  difficult  to  conceive  that  most  cases 
of  subsequent  incontinence  take  origin  from 
the  pre-operative  state,  therefore  to  prolong 
the  operation  by  some  trivial  variation  in 
technic  in  the  hopes  of  forestalling  this  con- 
sequence— is  a  questionable  hazard.  To 
indulge  in  refinement  of  dissection,  designed 
to  preserve  sexual  potency,  would  seem 
hardly  likely  to  capture  the  fancy  of  most  of 
these  aged  invalids — considering  the  stake. 

[l6o; 


BY-WAYS  OF  PROSTATECTOMY 

To  dwell  on  the  importance  of  a  rapid  opera- 
tion is  well  enough,  but  to  bring  into  view  the 
possibilities  of  the  pre-operative  and  post- 
operative attention  is  the  only  way  to  get  a 
perspective  of  the  brilliancy  of  the  results 
obtainable  in  the  surgical  care  of  prostatic 
hypertrophy  and  obstruction  of  the  aged. 

Here  the  special  training  of  the  genito- 
urinary surgeon  seems  to  be  of  some  advan- 
tage. In  considering  the  pre-operative  period, 
i.e.,  the  care  of  the  patients  leading  up  to  the 
operation — by  way  of  illustration,  the  cases 
may  be  divided  in  two  classes. 

The  first  class  may,  in  reaUty,  be  a  first- 
class  surgical  risk,  in  good,  general  health 
without  cardiac,  arterial  or  renal  impair- 
ment beyond  the  loss  of  resiliency  to  be  looked 
for  at  that  age;  the  patients  in  no  way  worn 
by  a  urinary  infection  or  by  undue  frequency 
of  micturition;  these  are  the  good  statistic 

makers  for  whoever  operates  on  them. 
II  [i6i] 


BY-WAYS  OF  PROSTATECTOMY 

The  second  class  present  a  different  problem. 
In  this  class  drop  the  cases  which  are  not  good 
surgical  risks ;  aside  from  their  cardio- vascular 
systems  which  may  hold  a  warning,  their 
renal  integrity  has  not  only  suffered  perma- 
nent changes,  but  is  under  the  influence  of  a 
functional  impairment  due  directly  to  the 
urinary  obstruction  and  infection.  Add  this 
general  systemic  influence  of  faulty  renal 
elimination  to  the  influence  of  sleeplessness, 
dysuria,  obstipation  and  septic  absorption  in 
a  subject  already  feeble  from  advanced  age 
and  the  picture  from  a  surgical  viewpoint 
looks  unpromising;  and  yet,  what  may  be  ac- 
complished for  these  patients  by  way  of  turn- 
ing them  into  fairly  good  surgical  risks  is 
oftentimes  surprising. 

To  gain  the  prize  in  these  cases  one  must 
advance  slowly  and  with  caution.  To  put 
these  patients  in  bed,  unless  already  bed- 
ridden, is  to  invite  the  machinery  to  lay 

[162] 


BY-WAYS  OF  PROSTATECTOMY 

down  its  burden.  To  shock  the  patients 
with  sudden  and  violent  catharsis  is  an  error 
which  is  sometimes  a  fatal  error.  The 
bladder  is  to  be  drained  with  a  catheter, 
urinary  antisepsis  is  to  be  employed  to  the  end 
that  the  back  pressure  on  the  kidneys  is 
relieved  that  their  congestion  may  subside, 
that  their  function  of  elimination  may  be 
slowly  resumed,  that  septic  absorption  may 
cease.  To  burden  these  kidneys  by  giving 
excessively  of  water  to  drink  is  to  force  them 
without  purpose;  gentle  diaphoresis,  if  indi- 
cated, is  of  more  advantage.  As  to  a  pre- 
liminary general  anesthesia  and  operation  to 
open  the  bladder  supra-pubically  or  perineally 
for  the  purpose  of  drainage  or  to  shorten 
another  operation,  is,  in  the  writer's  humble 
opinion,  without  excuse;  to  inflict  that  added 
surgical  shock  on  an  aged,  septic  and  feeble 
individual  is  to  court  a  fatal  issue  as  a  final 
result.    The  drainage  can  be  accomplished 

[163] 


BY-WAYS  OF  PROSTATECTOMY 

with  a  catheter  or  a  quick  supra- pubic  section 
under  local  anesthesia,  if  need  be. 

The  preparation  of  the  patient  for  the 
operation  should  not  be  left  to  attendants 
versed  only  in  getting  ready  of  younger 
adults,  with  good  margin  of  vitality.  Food 
of  a  Kquid  nature  and  drink  should  be  given 
up  to  within  a  few  hours  of  the  anesthesia  or 
just  so  the  stomach  will  be  empty;  that  the 
shock  of  fasting  is  not  felt.  The  pre-operative 
catharsis  should  be  led  up  to  gently  for  a 
couple  of  days  before  operation  and,  finally, 
a  rectal  irrigation  can  be  carefully  given  just 
before  operating.  An  opiate  an  hour  or  two 
before  the  anesthesia  smooths  the  way. 

Of  the  operation  itself  we  have  made 
mention.  The  anesthesia  is  another  chapter 
to  be  put  in  the  hands  of  an  expert  on 
anesthesia. 

The  post-operative  care  of  these  patients 
begins  the  minute  the  operation  is  completed. 

[164] 


BY-WAYS  OF  PROSTATECTOMY 

As  gently  as  these  patients  are  led  to  opera- 
tion, as  gently  are  they  to  be  led  away  from 
it.  The  careless  loss  of  body  heat  through 
exposure  is  to  be  avoided.  A  "good  quality" 
of  pulse  is  to  be  made  sure  of — if  need  be  by 
intravenous  administration  of  saline  solution. 
The  patient  is  allowed  to  come  out  of  his 
light  anesthesia  without  disturbance.  Thirst 
is  to  be  quenched  by  water  and  small  quanti- 
ties of  liquid  food  given  as  soon  as  the 
stomach  is  ready  for  it.  Restlessness  is  to 
be  relieved  by  a  further  administration  of 
morphine  if  this  is  wonying  the  patient;  for 
the  wear  and  tear  of  such  restlessness  is  more 
costly  than  the  effect  of  a  little  anodyne.  In 
twenty-four  hours,  or  as  soon  as  possible,  he 
should  be  sitting  up,  with  a  watch  kept  on  the 
pulse  and  the  patient  for  signs  of  undue 
fatigue. 

The  bodily  habit  of  activity  in  the  aged  is 
their  sheet  anchor  and  a  return  to  such  activity, 

[165] 


BY-WAYS  OF  PROSTATECTOMY 

as  each  one  is  accustomed,  is  the  goal  toward 
which  each  must  be  directed  with  as  little 
loss  of  time  as  possible. 


[i66] 


X 

THE  GONOCOCCUS 


CHAPTER  X 

THE  GONOCOCCUS 

From  a  purely  academic  viewpoint  this 
organism  presents  a  problem  of  persuasive 
interest. 

For  a  good  many  years  now  the  price  of 
gonococcic  infection  paid  by  unsuspecting 
humanity  has  been  an  open  book  to  the 
medical  profession  so  that  there  is  no  need 
to  include  that  here.  The  royal  indifference 
with  which  the  world  of  medicine  has  swept 
by  this  little  king  of  depopulators,  only 
stooping  to  gather  in  the  coins  it  scatters  on 
its  silent  tour  of  civilization,  promises  some 
day  to  make  delectable  substance  for  debate 
From  a  scientific  standpoint  the  pathological 
extensions  of  this  infection  offer  so  few  new 
surprises,  that  relatively  little  scientific  interest 

[169] 


THE  GONOCOCCUS 

can  be  expected.  From  the  standpoint  of 
our  ethical  obHgation  to  society  this  infection 
is  attended  with  an  importance  in  exact 
proportion  to  society's  danger  from  it. 

When  thinking  people  of  to-day  come  to  a 
knowledge  of  the  "professional  silence,"  for 
instance,  which  seals  the  lips  of  the  physician 
and  at  the  same  time  the  doom  of  countless 
trusting  women  at  the  marriage  altar,  then 
may  arise  questions  which  at  present  it  is 
not  perfectly  convenient  to  answer. 

There  are  a  certain  number  of  blind  people 
in  the  world  to-day —  statistics  say  about  25 
per  cent,  of  them —  who  owe  their  condition 
not  so  much  to  the  virulence  of  this  germ 
as  indifference  to  and  ignorance  of  it.  Many 
of  these  people  have  learned  the  etiology  of 
their  bhghted  existence  and  are  making  it 
their  life  work  to  save  others  from  the  same 
fate. 

The  thoughtful  reader  will  readily  see  that 

[170] 


THE  GONOCOCCUS 

we  need  only  make  relatively  short  excursions 
into  the  realm  of  the  gonococcus  to  discover 
the  riches  of  that  germ  as  an  object  of  dis- 
cussion. That  it  has  been  found  to  be  an 
unpleasant  topic  upon  which  to  exchange 
views  and  thus  increase  the  sum  of  human 
knowledge  is  the  best  excuse  that  can  be 
offered  by  the  medical  profession  as  an  explan- 
ation of  the  fact  that  false  pride  and  preju- 
dice have  had  the  upper  hand  of  reason. 

The  motives  which  prompt  teachers  and 
parents  to  foster  the  state  of  unconsciousness 
of  sex  in  the  young  are  worthy  of  the  deepest 
respect,  but  the  trained  medical  mind  which 
carries  this  thought  a  step  further  and  weighs 
the  cost  of  what  is  now  a  traditional  fancy 
against  the  cost  of  what  may  be  an  actual 
tragedy,  knows  the  imperative  necessity  of 
anti-dating  sexual  function  by  sexual  knowl- 
edge as  it  exists  to-day.  To  expose  the 
young  to  drowning,  let  us  say,   is  kinder 

[171] 


THE  GONOCOCCUS 

than  to  expose  them  to  the  danger  of  sex 
death  or  indefinite  and  loathsome  infec- 
tiousness. Once  one  generation  of  young  are 
safe-guarded  by  timely  training,  succeeding 
generations  without  the  silly  confusion  of 
self-consciousness  will  reflexly  forewarn  their 
progeny. 

If  human  laws  and  regulations  are  worth 
anything,  there  should  be  one,  until  the 
infection  is  uprooted,  which  would  make 
marriage,  without  a  certificate  of  fitness  to 
marry,  a  criminal  offense.  To  be  compelled 
to  resort  to  such  means  is  abscheulich,  but  to 
feed  our  young  on  false  conceptions  of  the 
future  by  withholding  the  truth  is  to  barter 
honor  for  dishonor. 

Through  many  interesting  phases  the  gono- 
coccus  has  worked  its  way  up  from  relative 
obscurity  to  a  position  of  racial  importance. 
All  civilized  countries  are  thoroughly  impreg- 
nated with  it  and  yet  it  would  be  hard  to  find 

[172] 


THE  GONOCOCCUS 

any  infection  to  which  human  flesh  is  heir, 
that  is  as  easy  to  prevent  as  is  gonococcic 

infection. 

How  this  interesting  problem  can  get  by 
without  more  academic  interest  being  shown 
it,  even  though  the  medical  profession  as  a 
whole  is  so  indifferent  to  it,  passes  under- 
standing. The  superficial  reasoning  which 
has  surrounded  the  whole  subject  of  prostitu- 
tion and  the  continuous  persecution  of  these 
condition-made  creatures  who  are  struggUng 
on  under  the  burden  society  imposes,  but 
startles  sane  reflection  and  adds  little  or 
nothing  toward  the  extermination  of  sex 
sustaining  sickness. 

A  good  deal  of  effort  has  been  expended  in 
trying  to  teach  young  males  how  to  suppress 
and  arrest  the  development  of  the  sexual 
instinct— a  perfectly  plausible  procedure  if 
one  could  be  convinced  of  its  moraUty.  And 
so,  here  and  there,  by  this  means  and  that, 

[173] 


THE  GONOCOCCUS 

the  isolated  wellwishers  of  humanity  go 
snipping  away  at  the  stalk  and  the  leaves 
of  the  weed  which  has  buried  its  roots  so 
securely  in  the  soil  of  our  society. 

The  intelligent  reader  will  observe  that  I 
have  carefully  avoided  even  a  suggestion  as 
to  the  solution  of  this  interesting  problem. 
To  give  the  answer  with  the  riddle  spoils  the 
game. 


[174] 


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